Sunnyside Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one (1) out of three (3) sampled residents' (Resident 1) personal property from theft and loss in accordance with the facility's Policy and Procedure (P&P) titled Theft and Loss when the facility lost Resident 1's wallet containing his California Identification Card (CAID). The facility failed to:1. Follow up and replace Residents 1's missing CAID This deficient practice resulted in Resident 1 not having his CAID replaced for over two (2) years after the loss was reported and had the potential to cause Resident 1 to feel helpless and forgotten.

Inspectors wroteBased on interviews and a review of records, the facility failed to ensure one of three sampled residents (Resident 1) had her right to receive visitors of her choice and to have her visitation preferences considered prior to imposing restrictions. This deficient practice resulted in Resident 1 being unable to receive visits from her son in her room as she preferred, and had the potential to negatively impact her emotional well being, quality of life, and resident rights.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary activities of daily living ([ADLs] daily self-care activities) care and services for two of three sampled residents (Resident 1 and 2), who were dependent (helper does all the work) on staff for incontinence care (the help someone gets when they have accidental urine or stool leaks). This was evidenced by the following: 1. Resident 1 was observed with a soiled incontinence brief (diaper) containing urine and stool.2. Resident 2 was observed with urine-soiled towel positioned between her legs, which was not consistent with facility practice for managing incontinence. These deficient practices placed Resident 1 and 2 at risk for skin breakdown, worsening skin integrity, infection, discomfort, compromised dignity and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection control and prevention designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection for one of three sampled residents (Resident 1) by failing to:1. Ensure ongoing assessment and monitoring of Resident 1's gastrostomy tube ([GT] a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition) for signs of deterioration or contamination.2. Ensure appropriate infection prevention measures were implemented for Resident 1 being treated for suspected scabies (a contagious skin infestation caused by tiny, [mites]- closely related to spiders and ticks). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive person-centered Care Plans were reviewed and revised by the Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) when a resident (Resident 5) refused care for one of four sampled residents (Resident 5). This deficient practice had the potential for Resident 5's care needs and preferences to be unidentified and Resident 5 to continue refusing care which could negatively affect her quality of life and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 5), who required two-person assistance from staff to perform her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily), that those ADLs were performed in a timely manner. This deficient practice had resulted in Resident 5 feeling neglected and had the potential to negatively impact her dignity and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse Supervisor (RNS) 1 completed and accurately documented the Discharge Summary for one of two sampled residents (Resident 6) when Resident 6 was discharged home on 4/13/2026. This deficient practice resulted in Resident 6's skin condition not depicted accurately upon Resident 6's discharge and had the potential for his continuity of care to be interrupted and/or delayed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure facility's water boiler was maintained and in proper working condition to provide residents with consistent access to hot water for bathing and personal hygiene. These failures resulted in residents being unable to access hot water consistently for bathing, which is necessary to maintain comfort, hygiene, and a safe living environment.

Inspectors wroteBased on observations, interview and record review the facility failed to have a safe, and homelike environment for six of five sampled residents ( Resident 56, 171,220,273,139 and Resident 31. The facility failed to:1. Ensure the room clocks for Resident 139, 31, and 56 room displayed the correct time. This failure had the potential to cause confusion and disorientation for Resident 139, Resident 31 and Resident 56 and staff.2. Ensure hot water was consistently available at the bathroom sink in Resident 56's room and ensure hot water was available for showers for Resident 171, 220, and 273. This resulted in delays in providing Resident 56 with bed baths and other activities of daily living (ADL-daily self-care activities) and Resident 171, 220 and 273 unable to shower in comfortable water temperature due to the lack of consistently available hot water.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for two of three sampled residents (Residents 242 and 180). The facility failed to:1. Sanitize the blood pressure (BP) cuff and stethoscope(instrument used to hear heart beat) before using them during Resident 242's 9:00 a.m. medication administration.2. Perform hand hygiene on two separate occasions while takingResident 242's blood pressure during Resident 242's 9:00 a.m. medication administration.3. Perform hand hygiene before distributing the lunchtime meal trays.4. Perform hand hygiene while providing care to Resident 180. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to privacy and dignity was maintained during care and while in common areas for one of three sampled residents (Resident 256). This failure resulted in Resident 256 being visibly exposed on multiple occasions, with legs and indwelling urinary catheter (foley catheter-a tube inserted into the bladder [tubing] drains the urine into a collection bag) tubing observable to others, which had the potential to cause embarrassment, decreased self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure three of four sampled residents (Resident 241,193, and 120) call light device was within reach to each resident. This deficient practice had the potential to result in the residents being unable to summon health care workers for assistance with care and services as needed.2. Provide a safe and appropriate bed frame for one of one sampled resident (Resident 58). This deficient practice placed the resident at risk for skin breakdown, discomfort, and an inability to safely position himself in bed, creating a potential for accident hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool) accurately reflected the care and services provided to one of three sampled residents (Resident 7)This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 7's health status and individual healthcare needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 139) received a bed bath and an incontinent (loss of the ability to control urine and feces) pad change on 4/7/2026. This deficient practice resulted in Resident 139 experiencing itching and scratching from a wet incontinent pad, lowered self esteem, and appearing emotional while in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 242 received ferrous sulfate (iron - mineral) and carvedilol (blood pressure medications) as prescribed on 4/10/2026 at 9:00 a.m. This failure had the potential to prevent the medications from maintaining a therapeutic dose level (a level in the blood needed for the medication to work effectively) when medications are not administered according to the physician's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent % (percent) during medication pass for one of seven sampled residents (Residents 242) by failing to:1. Administer ferrous sulfate (iron-mineral) and carvedilol (blood pressure medication) as prescribed by Resident 242's physician. These deficient practices resulted in a medication administration error rate of 6.9%, which exceeded the 5% threshold and medications not to maintain a therapeutic dose level (maintain a certain level in your blood to work well) when not administering medications according to physician's orders.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were stored safely and in accordance with manufacturer expiration dates and facility policy. The facility failed to:1. Remove expired medications, expired vaccines from medication rooms2. Replaced an outdated insulin emergency kit (Ekit- emergency medication used to treat high blood sugar) after it was last on 11/16/2025. These failure had the potential to result in ineffective treatment, delayed access to emergency medications, and compromised resident safety for residents who received these medications.

Inspectors wroteBased on interview and record review, the facility failed to provide dental services for one of three sampled residents (Resident 198). This failure had the potential to lead to weight loss, inability to chew effectively, pain, or infection of the mouth.

Inspectors wroteBased on observation interview and record review the facility failed to ensure lunch trays for two of two sampled residents (Resident 24 and Resident 5) were served in a timely manner. This failure resulted in Resident 24 and Resident 5 receiving their lunch trays more than one hour late.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and thaw food items safely. The facility failed to:1. Ensure garlic powder, corn starch, kosher salt, and macaroni were labeled with open dates.2. Ensure frozen chicken was thawed under cold running water.3. Ensure the temperature of milk on the breakfast tray line (where food is plated for service) was maintained below 41 degrees Farenheight ( F unit of measure). These failures had the potential to expose residents to food borne illnesses (any illness resulting from eating food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate and complete medication documentation for two of six sampled residents (Residents 214 and 242).1. For Resident 242, the MAR indicated the resident received ferrous sulfate (iron) on 4/10/2026 at 10:03 a.m., but the medication was observed not to have been administered during the medication pass.2. For Resident 214, the Medication Administration Record (MAR) documented that the resident received a COVID 19 vaccine (respiratory illness) and a pneumonia (PNA respiratory infection) vaccine on 3/12/2026 at 11:29 p.m.; however, both vaccines were observed in the medication refrigerator on 4/7/2026, indicating the vaccines were not administered as documented. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure coordinated and comprehensive hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) services for one of three sampled residents (Resident 7)The facility failed to:1. Develop and implement an individualized and person-centered care plan for Resident 7 by failing to ensure coordination of care between the facility and the hospice provider for Resident 7. 2. Ensure Resident 7 hospice eligibility were reassessed after showing clinical improvements. These failures had the potential for Resident 7 to receive care that did not reflect her current clinical condition, needs, or appropriate hospice eligibility.

Inspectors wroteBased on interview and record review the facility failed to:Ensure physician ordered laboratory test (a medical test of a sample oof blood) was collected in a timely manner for 2 of 10 residents (Resident 1 and Resident 9). Ensure the physician was notified the laboratory test ordered was not performed for 2 of 10 residents (Resident 1 and Resident 9). This failure had the potential to result in delay in diagnosis, lack of timely medical intervention, and worsening of residents' condition due to the physician not being notified that the ordered laboratory tests were not completed.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents (Resident 1) was free from rough handling and treated with dignity and respect, while being assisted by Certified Nurse Assistant (CNA) 1. This deficient practice resulted in a purplish discoloration to the left thumb, emotional distress, and loss of dignity and trust in staff.

Inspectors wroteBased on interview and record review the facility failed to ensure that required fall-prevention interventions were implemented for one of three residents (Resident 1) by failing to:1. Implement the Falling Star Program (is a fall prevention initiative used to identify and alert staff, that a patient or resident is at high risk of falling) upon admission.2. Ensure the use of floor mats (safety devices, often specifically designed to be low-profile and impact-absorbing, used to help prevent falls and reduce the severity of injuries if a fall occurs).3. Obtain a bed alarm (a safety device for residents at risk of falling, typically a pressure-sensitive pad placed on the bed).4. Revise Resident 1's care plan after the first fall.5. Notify the physician of Resident 1's unsafe behavior (repeatedly attempting to get out of bed). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report suspected abuse to the State Survey Agency within 2 hours after the allegation for one of three sampled residents (Resident 1). As a result of this deficient practice, facility residents including Resident 1 were placed at risk for potential continued abuse, injuries, psychosocial harm and delay in care and investigation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 10), who was admitted to the facility from a General Acute Care Hospital (GACH) on [DATE], was not administered Baclofen (a medication that relaxes the muscles to relieve spasm, tightness, and cramps) due to a known side effect of confusion, when: 1. Registered Nurse (RN) 1 did not review Resident 10's entire Discharge Instructions dated [DATE] and [DATE] for accuracy, prior to transcribing the orders in Resident 10's chart. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), whose preference to have a shower instead of a bed bath, was honored. This deficient practice resulted in Resident 9 receiving bed baths on multiple occasions when his preference was to have a shower. This deficient practice had the potential for Resident 9 to feel disrespected and uncomfortable during his stay at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was created to include a Fall Management Program for one of two sampled residents (Resident 16), who was assessed at high risk for falls, per the facility's policy and procedure (P/P). This deficient practice resulted in the care needs for Resident 16 not being thoroughly addressed and placed Resident 16 at risk for falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a QAPI (Quality Assurance/Quality Assurance and Performance Improvement - a data driven proactive approach to improvement used to ensure services are meeting quality standards) plan was implemented after being made aware of a deficient practice and failure of the facility, when one of three sampled residents (Resident 10), who was admitted to the facility from a General Acute Care Hospital (GACH) on 8/15/2025, was administered Baclofen (a medication that relaxes the muscles to relieve spasm, tightness, and cramps) with a known side effect of confusion, when: 1. Registered Nurse (RN) 1 did not review Resident 10's entire Discharge Instructions dated 8/14/2025 and 8/15/2025 for accuracy, prior to transcribing the orders in Resident 10's chart. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was free from neglect when staff did not provide timely incontinence care and left Resident 1 soiled with urine and feces, with a towel placed between his legs and failed to perform incontinent care. This failure compromised Resident 1's dignity and created potential for harm including risk for skin breakdown, and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary treatment and services for one of two sampled residents (Resident 1), when Resident 1, who had an existing pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), was left in urine and feces for an extended period of time. This failure had the potential for worsening of pressure ulcers and placed Resident 1 at risk for further skin breakdown, infection, and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 2) who was incontinent (involuntary voiding of urine and stool) of bowel (stool) and bladder (urine), and had a urinary tract infection (UTI- an infection in the bladder/urinary tract) perineal care (the cleaning and maintenance of the area between the anus and genitals, which is essential for maintaining good hygiene, preventing infections, and promoting overall health and well-being) was properly provided for one of three sampled residents (Resident 2). This failure had the potential for Resident 2 to have an exacerbation (the worsening of a disease, symptom, or problem) of her current UTI which could result in unnecessary hospitalization and sepsis (a life-threatening blood infection).

Inspectors wroteBased on interview and record review, the facility failed to prevent an avoidable, facility acquired, unstageable (when the stage is not clear, the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) pressure injury (damage to the skin and underlying structures caused by unrelieved pressure) for one of three sampled residents (Resident 1) by: 1. Failing to reposition Resident 1 every two hours as per physician's orders. 2. Failing to implement its Policy and Procedure (P&P) titled, Wound Care Suggestions and Documentation, dated 2/2025 which indicated Residents who were unable to turn independently would be turned and repositioned every two hours and would be checked for incontinence (loss of voluntary control of bowel and bladder movements) every two hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) to address offloading (minimizing or removing weight placed on a bony prominence to help prevent and heal ulcers) while Resident 1 was up in the wheelchair daily. This deficient practice had the potential to contribute to the decline in Resident 1's unstageable (when the stage is not clear, the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) pressure injury (unrelieved pressure causes damage to the skin and underlying structures).

Inspectors wroteBased on interview, and record review, facility failed to ensure a resident (Resident 5) who had impaired mobility, orders for physical therapy ([PT] a healthcare specialty that focusses on restoring, maintaining, and improving physical function and movement) and occupational therapy ([OT] a healthcare specialty that focusses and helps people of all ages participate in meaningful daily activities) evaluation and treatment were carried out for one of five sampled residents (Resident 5). This deficient practice resulted in a 30-day delay in treatment and services for Resident 5 and placed Resident 5 at risk for further decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Restorative Nurse Assistant 1 ([RNA 1] assists patient in maintaining and improving their physical and cognitive function, primarily focusing on maximizing their independence with activities of daily [ADLs] activities such as bathing, dressing and toileting a person performs daily) doffed (carefully removing personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the risk of contamination to self, other, or the surrounding environment) upon exiting a resident ' s room (Resident 4), who was on Enhanced Barrier Precautions ([EBP] involve gown and glove use during high contact resident care activities for residents at risk for Multidrug-Resistant Organisms ([MDRO] bacteria that have become resistant to [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's Rehabilitation (Rehab) room equipment was not readily accessible for unauthorized use by residents and/or visitors or used as a weapon to hit for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure the Rehab room and equipment located in the Rehab room was secured and supervised at all times to prevent unauthorized access by residents and/or visitors. 2. Ensure Resident 1 did not gain access to a Dowel (a pole or rod used in rehabilitation to improve shoulder mobility and strength) from the facility's Rehab room without staff knowledge. 3. Ensure Resident 1 did not use a Dowel to physically assault Resident 2 and Resident 3. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was not subjected to abuse by Resident 1, when Resident 1 without authorization obtained a Dowel (a pole or rod used in rehabilitation to improve shoulder mobility and strength) from the facility's Rehabilitation (Rehab) room and used the Dowel as a weapon and struck Resident 1 on her right arm, right shoulder and face. The facility failed to: 1. Ensure the Rehab room and equipment located in the Rehab room was secured and supervised at all times to prevent unauthorized access by residents and/or visitors. 2. Ensure Resident 1 did not gain access to the Dowel from the facility's Rehab room without staff knowledge or permission. 3. Ensure Resident 1 did not use the Dowel as a weapon to physically assault Resident 2 and Resident 3. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) responsible party ' s (RP 1) complaint ' s regarding Resident 1 ' s Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily) care was formally logged as a grievance (complaint) and investigated as indicated in the facility ' s policy and procedures (P&P) titled, Grievances/Complaints, Filing. This deficient practice resulted in a violation of Resident 1 ' s RP rights and a potential delay in the care and delivery of services to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct an Interdisciplinary Team ([IDT] health care professionals who work together with the resident to plan the residents plan of care) meeting timely for one of three sampled residents (Resident 1) and failed to ensure Resident 1 ' s Responsible Party (RP1) was given the opportunity to meet with the IDT regularly per the facility ' s policy and procedure (P&P) titled, Care plans, Comprehensive Person Centered. These deficient practices resulted in a violation of RP1 ' s rights and had the potential to delay person centered care interventions to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received necessary care and treatment by failing to: a. Assess Resident 1's left foot after Restorative Nursing Assistant (RNA1) ' s water bottle fell on Resident 1's left foot on 9/3/2024. b. Reassess and monitor Resident 1's left big toe after a change of condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition relating to an infection) on 10/3/2024 when Resident 1 had worsening pain on Resident 1's left big toe with swelling, tender to touch and with yellow minimal drainage. These failures had the potential for Resident 1's left big toe wound to decline, affect the healing process, and not implement appropriate interventions in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident did not develop a Stage II ( partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury ( a localized pressure related damage to the skin and or underlying tissue) to sacrococcyx (bones at the base of the spine) area which progressed to a Stage IV (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin) pressure injury for one of one sampled residents (Resident 36). The facility failed to: 1. Ensure Resident 36 received treatment to a Stage II sacrococcyx pressure injury for 14 days from 11/8/2024-11/21/2024 as ordered by the physician. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who was a high risk for falls and injuries, did not fall and sustain injury for one of three sampled residents (Resident 136). The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 2) did not leave Resident 136 unsupervised in the bathroom to go to assist another resident. 2. Ensure CNA 2 followed the facility's policy and procedure (P&P) titled, Fall Prevention and Management Program dated 2/2025, which indicated the facility must ensure that each resident receives adequate supervision and assistive devices ( devices that are designed to assist a person to perform a particular task) to prevent accidents. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure Lysol bleach cleaner was not stored in the dry food storage area. b. Ensure the drain to the ice machine was free from dirt and debris. c. Ensure prepared food items in the refrigerator had the prepare date and the use by date. d. Ensure the freezer temperature logs were completed daily. These failures have the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and put residents at risk for cross contamination (unintentional transfer of harmful bacteria from one object to another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for two of six sampled residents (Resident 22 and Resident 100) by failing to: 1. Ensure call light (communication device used by residents to enable them to call for help from staff) was answered in a timely manner when Resident 22 was complaining of pain and screaming for help. 2. Ensure Resident 100's call light was within reach and not clipped in the curtain when resident was asking for someone to help her. These failures had the potential to put Resident 22 and 100 at risk for delayed treatment and care which lead to not meeting their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication error rate was less than five percent (%). Ten medication errors out of 29 total opportunities contributed to an overall medication error rate of 34.48 % for four of six residents (Resident 129, 80, 12, 230) observed during medication administration (MedPass). The facility failed to ensure: 1. Resident 129's Amlodipine (a medication used to treat high blood pressure) 5.0 (five) milligrams ([mg] - a unit of measure for weight) powder from the crushed medication was mixed with water before administration and medication cup was rinsed with water to ensure resident received the full dose via gastrostomy tube ([GT] - a soft tube surgically inserted into the stomach to administer medications, fluids, and nutrition). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one out of six sampled residents (Resident 12) was free of a significant medication error. The facility failed ensure Resident 12 was administered medication that included seizure (convulsions, is a sudden rush of abnormal electrical activity in your brain) medications, Phenytoin and Phenobarbital and an anticoagulant (blood thinner) medication Heparin was administered as ordered and not close to the next scheduled dose for Phenytoin and Heparin. (Cross reference: F759) The deficient practice of failing to administer medications in accordance with the physician orders increased the risk that Residents 12 may experience adverse reactions, complications, that could lead to a decline in the residents' condition, harm, or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control practices by failing to: 1. Ensure oxygen tubing and bags were changed and labeled weekly for Residents 126 and 500. 2. Ensure tube feeding and water bags were changed and labeled for Resident 218. 3. Ensure the licensed nurse removed her personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments.) when exiting Resident 517's room and prior to walking out into the hallway. 4. Ensure the Certified Nursing Assistant (CNA) will call housekeeping to properly clean the floor in Resident 106's room after feces are found scattered in the floor. 5. Ensure a visitor was educated and informed about the use of PPE) was worn when entering Resident 169's room who had Candida Auris(C. [...]

Inspectors wroteBased on observation, interview, and record review , the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect on one of three sampled residents (Resident 17) by standing over the resident while assisting her during a meal. This failure had the potential to result in decreased self-esteem and self-worth on Resident 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistance (CNA7) close the privacy curtain to ensure a resident would not be visually exposed to the roommates and others while providing personal care for residents 1 out or 10 sample resident (Resident 23). This deficient practice violated the resident's right for privacy.

Inspectors wroteBased on interview and record review, the facility failed to reassess the 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) for one of three sampled residents (Resident 3) by failing to ensure PASRR level 1 was submitted when the resident was diagnosed with mental illness and was placed on antipsychotic medicine (medicines used to treat mental illnesses ). This deficient practice placed Resident 3 at risk of not receiving necessary care and services they need.

Inspectors wroteBased on interview and record review the facility failed to ensure two of five reviewed residents (Resident 129 and 80) were administered blood pressure medications safely and in accordance with physician's orders and by failing to ensure: 1. Resident 129's Amlodipine (a medication used to treat high blood pressure) 5.0 (five) milligrams ([mg] - a unit of measure for weight) powder from the crushed medication was mixed with water before administration and medication cup was rinsed with water to ensure resident received the full dose via gastrostomy tube ([GT] - a soft tube surgically inserted into the stomach to administer medications, fluids, and nutrition). This deficient practice placed Residents 129 at risk for GT clogging leading to discomfort/pain and GT replacement and not receiving full dose of BP medication (Amlodipine). 2. [...]

Inspectors wrote3. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following unspecified cerebrovascular disease (condition that affect the blood vessels in the brain and spinal cord) affecting left non-dominant side and unspecified asthma (chronic lung disease). During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognition was not intact, and was dependent for eating, hygiene, and bathing. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor food request and food preferences of one of two sampled residents (Resident 76) by ensuring requested food is provided and accommodated. This failure had the potential to place Resident 76 at risk of not having her nutritional needs met.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to establish a system for: 1. Medication Management and safety by reducing medication errors and ensure accurate medication administration to enhance resident safety. 2. Falls and fall -related injuries by minimizing the occurrence of falls among residents and reduce the severity of fall-related injuries. 3. Pressure ulcers monitoring for residents who are at risk for developing or acquiring pressure ulcers. These deficient practices resulted for residents not receiving medically related necessary care, resulting in medication errors, injury related to falls, lack of monitoring and document pressures injuries.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program policy when the antibiotic (a substance used to kill bacteria and to treat infections) did not meet Loeb's or McGeer's Criteria (criteria used to determine appropriate use of antibiotics) for two of three sampled residents (Resident 98) receiving ampicillin (antibiotic used to treat bacterial infections). This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer, educate, and track influenza vaccinations for residents per facility's policy for one or five sampled residents (Resident 218). This failure had the potential to place all residents at risk for infection of influenza.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer, educate, and track coronavirus vaccinations for residents per facility's policy for two or five sampled residents (Resident 218 and Resident 121). This failure had the potential to place all residents at risk for infection of coronavirus.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate no more than four residents, by failing to ensure rooms provide at least 80 square feet ([sq. ft.] unit of measurement) per resident in multiple resident bedrooms. The insufficient space could lead to inadequate nursing care to the residents. This failure had the potential to decrease the resident's privacy, quality of care and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement resident centered care plans for one of three sampled residents (Resident 1) who had a history of a craniectomy (procedure which permanently removes a portion of the skull to access the brain) and pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: 1. Ensure Resident 1 ' s Responsible Party (RP) 1 was provided updates regarding Resident 1 ' s wound care treatments as agreed upon during the Interdisciplinary team meeting (IDT health care professionals from different professional disciplines who work together to manage resident goals) meeting held on 11/1/2024. 2. Ensure Resident 1 was wearing a helmet during her transport to the General Acute Care Hospital (GACH) 2 on 11/7/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff did not reverse (incorrectly classifying a healing pressure ulcer/injury) a pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 2). These deficient practices resulted in inaccurate wound staging for Resident 2 and had the potential in a delay in care and services leading to a decline in Resident 2 ' s physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident, who was assessed at risk for wandering (moving around inside the facility without awareness of personal safety, potentially putting themselves in harm's way), did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility for one of nine sampled residents (Resident 1). The facility failed to: 1. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility. 2. Develop a care plan with interventions addressing Resident 1's risk for wandering, to ensure the resident's safety, and prevent him from eloping from the facility. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a resident centered care plan for one of three sampled residents (Resident 1) who has a history of banging her arms against the side rails (a bar or board positioned at the side of the bed which help people get in and out of the bed and help reposition themselves in bed). This deficient practice placed Resident 1 at risk for skin bruising, skin tears and skin breakdown, and placed Resident 1 at risk for skin infection and a decline in health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff washed their hands with soap and water and wore the appropriate personal protective equipment ([PPE] specialized clothing or equipment that protects the wearer from infectious materials, injury, or the spread of illness) while providing care to one of four sampled residents (Resident 1) who was on contact isolation (direct or indirect contact with a resident and/or his or her environment including person's room or objects in contact with the person, that has an infection) due to a Clostridium difficile colitis ([C diff] inflammation of the colon caused by a bacteria) infection. These deficient practices resulted in facility staff not following infection prevention protocols and had the potential to spread infection amongst residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services for one of three sampled residents (Resident 1) by failing to: a. Notify the physician when Resident 1 had episodes of loose watery stool in a timely manner. b. Administer insulin ( medication used to treat high blood sugar) as ordered by the physician on 7/21/2024 at 12:00 p.m. dose. c. Notify the physician when Resident 1's blood sugar remained high despite administration of insulin. These failures had the potential for Resident 1 to have elevated blood sugar level that can lead to worsening of his condition. Resident 1 was transferred to general acute care hospital (GACH) for management of high blood sugar and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection prevention and control measures by failing to: a. Conduct fit testing (test to ensure they are wearing the proper size respirator to seal and prevent particles, that may cause infection, from entering the respiratory system) for a N95 mask (filtering facepiece respirator) on six of 10 staff members. b. Handle soiled linens in a safe and sanitary way by staff swinging the plastic linen bag back and forth towards the body before disposing it in a barrel outside the facility. These deficient practices had the potential to place residents at risk for the spread of infection and result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another).

Inspectors wroteBased on interview and record review the facility failed to implement their antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) on one of three sampled residents (Resident 1) by failing to monitor and address antibiotic (a substance used to kill bacteria and to treat infection) use. This failure had the potential for the resident to receive an inappropriate antibiotic and develop clostridium difficile infection ([C diff] highly contagious bacterial infection of the colon and caused symptoms such as diarrhea, and stomach pain).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when Certified Nurse Assistant (CNA) 3 and CNA 1 failed to perform hand hygiene in between resident ' s care and prior to entering and exiting resident room. This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of diseases and infection to the facility staff, residents, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide care consistent with professional standards for one of three sampled residents (Resident 1). The facility failed to: a. Inform Resident 1's physician regarding the removal of Resident 1's Peripherally inserted central catheter ([PICC] thin, soft tube inserted into the resident's vein for long term medication, nutrition, and blood draws) line. b. Monitor and assess the PICC line site after removal. This deficient practice placed Resident 1 at risk for bleeding and infection after the removal of the PICC line. Findings During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted on [DATE] with the diagnosis of osteomyelitis (swelling of bone tissue that is usually the result of an infection) of the vertebra (spine). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 36 sampled residents (Resident 145), were not left with feces (solid waste passed out of the body of a human or animal) on her clothing and stomach (belly) upon returned to the facility from general acute care hospital (GACH). This failure resulted in Resident 145 feeling of helplessness, neglect, and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and services for three of eight (8) sampled residents (Resident 141, 155 and Resident 164) by failing to: 1. Answer the call light for 30 minutes to three hours for Resident 141 when she called for help and failing to change incontinence brief ( diaper) after being soiled wet withy urine for hours in the bed. 2. Failing to provide privacy and towel to cover Resident 141 after showering. 3. Failing to change Resident 155 after the suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) leaked urine on Resident 155 gown for hours. [...]

Inspectors wroteBased on observation, interview, and record review, the licensed nurses failed to ensure pharmaceutical services included procedures to ensure accurate dispensing, administering of all drugs and biologicals to meet the needs of two of seven sampled residents (Resident 83 and 480) by failing to: 1. Ensure a licensed nurse administer the three Lidocaine 4% patches (medication used to help relieve pain) to the left hip, left knee and right knee on 2/6/2024 to Resident 83. This failure had the potential to result in ineffectively managing Resident 83's chronic pain. 2. Ensure three Lidocaine 4% patches were not left on Resident 83's bedside table unattended by a licensed nurse. This failure had the potential for other staff, visitors, or residents to access prescription medications at any time 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) by failure to: 1. Ensure foods stored in kitchen reach in refrigerator were dated, labeled, and discarded before the used by date (expiration dates). This failure had the potential to affect residents and result in pathogen (germ) exposure 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 to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 3) was treated with respect and dignity when Resident 3's roommate's visitor failed to knock and request permission before entering Resident 3's room during personal care. This failure had the potential to affect Resident 3's sense of self-worth and self-esteem and unnecessarily exposed resident to others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care for one of eight sampled residents (Resident 74). This failure resulted in Resident 74's toenail untrimmed and long with yellow substance under the toenails and had the potential to cause infection of the toenail and degrade self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Perform weekly weights, nutritional re-assessment and provide revised interventions for one of seven sampled residents (Resident 155) when Resident 155 lost 20.2 pounds from April 2023 to July 2023. This failure placed Resident 155 at risk for continued weight loss, and potential for malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough). 2. Provide breakfast tray and assistance during mealtime on 2/6/2024. This failure resulted in Resident 155 not having a breakfast meal tray on 2/6/2024 and felt neglected by facility staff and had the potential for depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act).

Inspectors wroteBased on observation, interview and record review, the facility failed to manage residents' pain for two of two sampled residents (Resident 110 and 460) by: 1. Failure to assess for pain prior to providing personal care. This failure resulted in Resident 110 suffer with pain while receiving personal care with facility staff. 2. Failure to follow physician order when Resident 460 was given acetaminophen with a pain scale (way to rate or measure resident pain) level of five (1-4 mild pain, 5-7 moderate pain) on 2/6/2024 and seven on 2/8/2024. This failure had the potential to not alleviate the pain for Resident 460.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure that a licensed nurse administer the three Lidocaine 4% patches (medication used to help relieve pain) to the left hip, left knee and right knee on 2/6/2024 to one of seven sampled residents (Resident 83) and not left on Resident 83's bedside unattended. This failure had the potential to result in ineffectively managing Resident 83's chronic pain and had the potential for other staff, visitors ,or residents to access prescription medications at any time.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served was palatable (food and drink pleasant to taste) and/or at the proper temperature for one of five sampled residents (Residents 71). This failure had the potential for Resident 71 to feel upset, affect her wellbeing, and poor meal intake that can lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) during medication administration for one of three sampled resident (Resident 168). This failure placed Resident 168 at risk for spread of infection between residents and staff had a potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another).

Inspectors wroteBased on interview and record review, the facility failed to implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for one of 36 sampled residents (Resident 148), by prescribing an antibiotic without meeting the criteria of their protocol (checklist or guide to initiate antibiotic) for urinary tract infection ([UTI] infection in any part of the urinary system). This failure had the potential to put Resident 148 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 70 of 96 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms. This failure had the potential to result in inadequate space to provide privacy, space during daily care and access during an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 1) when the facility failed to provide timely incontinence (having little or no control over urination or defecation) care (assistance in cleaning up a resident after toileting in a brief [adult diaper]) to Resident 1. Resident 1 was left to sit in a soiled, wet adult brief for at least an hour. (Cross referenced to F690) This deficient practice resulted in Resident 1 feeling uncomfortable, frustrated, fearful of getting a pressure sore (injuries to the skin and underlying tissue due to prolonged pressure and exposure to moisture) and deterred Resident 1 from eating her lunch at mealtime.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1 ) who was enrolled in the facility ' s bowel training program and assessed to be frequently incontinent (little or no control over urincation and/or bowel movements) of bowel and bladder, received the care and services to prevent urinary tract infections and maintain as much normal bladder and bowel function as possible. The facility failed to: 1. Ensure the nursing staff assisted Resident 1 timely after toileting in her incontinence briefs( adult diaper) (cross referenced to F550) 2. Ensure Resident 1 was involved in her care planning process involving bladder management which included the possibility of using a bedside commode for urination. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who could not bear weight on her left leg, was transferred using a mechanical lift according to the care plan and [NAME] (a communication tool to access important and resident data regarding care). Resident 1 was transferred from her bed using two staff to physically lift Resident 1 from her bed and fell. This deficient practice resulted in Resident 1 being lifted from her bed by two Certified Nursing Assistants (CNA 1 and CNA 2) who used Resident 1's underarms to attempt to transfer Resident 1 from her bed to a wheelchair. The two CNAs lost control of Resident 1 who slid from her bed and landed on her knees on the floor. Resident 1 was later found with swelling, bruising and an abrasion (a scrape) to her left knee. [...]

Inspectors wroteBased on observation, interviews, and record review facility failed to ensure Licensed Vocational Nurses (LVN) 1 doffed (removed) personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) after exiting resident's rooms of COVID 19 positive resident, and perform hand hygiene This failure had the potential of cross contamination and spread of infection with other residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a resident, who had a diagnosis of a diabetes mellitus (DM) type 2 [a chronic disease characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream] and was receiving Insulin [a hormone that lowers the level of glucose [a type of sugar in blood]) based on sliding scale (the increasing administration of pre-meal insulin dose based on the blood sugar [b/s] level before meals) coverage, did not have their b/s monitoring and insulin administration abruptly discontinued for one of six sampled residents (Resident 5). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) documented Activities of Daily Living (ADL) task provided on 9/12/2023 at 7:00 am to 3:00 p.m. for one of two (Resident 1) residents sampled. The deficient practice resulted in inaccurate depiction of care rendered and received by the residents.

Inspectors wroteBased on observation, interview and record review the facility failed to implement infection control practices to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1. ensure visitors and contractors including paramedics (emergency medical technician) wore N95 mask (a face mask that covers the wearer's nose and mouth to achieve a very close facial fit that filters particles from the air) during a Covid- 19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath [SOB]) outbreak (occurrence of cases of disease that is more than expected) in the facility started on 8/8/2023, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Medical Doctor (MD) was notified when one of three sampled residents (Resident 8) had a change of condition (COC) of low blood pressure, responsive only to pain stimuli and responsible party refusal to send Resident 8 to general acute care hospital (GACH) on [DATE]. This failure resulted in delay in diagnosis, care, treatment, and transfer of Resident 8 to a general acute care hospital (GACH).