Sunnyvale Post-Acute Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and implement fall prevention interventions for one of three sampled residents (Resident 1), when facility staff failed to monitor Resident 1 after lunch/activity and did not observe Resident 1 leave the dining/activity area. This failure resulted in Resident 1 having an unwitnessed fall in another resident's bathroom and placed Resident 1 at risk for potential injury.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse reporting policy and procedure for one of three sampled residents (Resident 1). This failure had the potential to compromise Resident 1's safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident1) when Resident 1's ability to hear was not coded on the MDS.Failure to accurately complete the MDS had the potential to compromise the facility's ability to develop and implement care plan interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was disposed properly when one of three facility garbage was overflowing. This failure had the potential to result in the spread of disease from vermin infestation and unsanitary environment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not administer medication as ordered by a physician for Resident 1. This failure had the potential to compromise the resident's health and care. Review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted on [DATE] and had diagnoses including essential hypertension (HTN-high blood pressure), hypotension (low blood pressure), and epilepsy (an abnormal activity in the brain causing seizures [uncontrollable jerking movements of the arms and legs, and loss of consciousness]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for one of three sampled residents (Resident 1) when: 1. Resident 1 was not accurately assessed for Fall Risk Observation/Assessment and Admission/readmission Evaluation/Assessment; and 2. Staff did not assist Resident 1 during toileting and left Resident 1 unsupervised inside the resident restroom. These failures resulted in Resident 1's unwitnessed fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1. Two bins with thawed, soft mighty health shake cartons were stored in a reach-in refrigerator with expired dates. 2. A 3-door reach-in refrigerator and a walk-in refrigerator did not have internal thermometers to monitor temperature. 3. A large yellow onion with 3 dark grayish green colored spots resembling mold on it was found in case of yellow onions in the dry storage room. 4. A plastic container half full of tuna salad stored was stored inside the walk-in refrigerator and did not have a use by date. 5. The ice machine air filter had black and dark gray debris on it, and the inside ice making parts were not cleaned and maintained according to manufacturer's instructions. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices when: 1. One certified nursing assistant (CNA) did not wash hands after providing care between two residents (Residents 96 and 52) who were on transmission-based precautions (are used to help stop the spread of germs from one person to another); 2. One resident (Resident 149)'s nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing was not changed after seven days according to facility policy; 3. The facility failed to ensure there was a plan in place to prevent the growth of Legionella (a bacteria that is found in water and can cause illness) in the facility's water supply; 4. One resident (Resident 6)'s oxygen filter was not changed according to facility policy; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dish machine consistently provided accurate temperatures and properly function for cleaning and sanitizing dishes, according to manufacturer's guidelines and standards of practice. This failure had the potential to result in widespread foodborne illness for 97 residents consuming food in the facility. (Cross Reference F802 and F812)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for three of four residents (Resident 83, 91, and 249) when: 1. Registered nurse F (RN F) addressed Resident 83 and 91, mama; and 2. Certified nursing assistant G (CNA G) addressed Resident 249, mama. These failures had the potential to affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect resident's care, health, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Multiple expired medications were stored in medication refrigerators (REF) 2 and 1; 2. Two insulin (injectable medication to lower blood sugar) pens identified in REF1 were not labeled with resident-specific information; 3. An oral inhaler was expired and identified in the active stock in the medication room (MR) 2; 4. Discontinued and expired and controlled medication in Medication carts 1 and 2; and 5. Licensed nurses left the medication on the medication cart unattended and the medication cart key on the top of the medication cart unattended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. A dietary staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine or maintaining the correct wash temperature. 2. Two Dietary Aides did not know how to properly test the sanitizer in the red bucket. These failures in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces that could expose residents to food-borne illness in a highly susceptible population of 97 residents.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure the Food and Nutrition Services Department, the kitchen, was free from pest and an effective pest control program maintained. This failure had the potential to contaminate food stored in the kitchen which could lead to widespread foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs were accommodated for five of 20 sampled residents (Residents 250, 249, 39, 25 and 48) when call light devices were not within reach of the residents. This failure had the potential for a delayed response and not meeting the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the Ombudsman's (a government employee who investigates, reports on, and helps settle complaints) contact information to all residents when the State Long-Term Care Ombudsman's contact information was not available in the resident's care and activity areas. This failure limited resident's rights to have a confidential avenue to talk about a concern and resolved issues at the lowest possible level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of the most recent survey of the facility (the survey results in a binder) was readily accessible to residents, and family members and legal representatives of residents when one of 20 sampled residents (6) and six non-sampled residents (20, 21, 27, 34, 43 and 68) stated they could not access the facility's most recent survey results. This failure potentially limited resident's rights to examine and receive the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney that authorizes another person to act on behalf of the resident) and completion of the Physician Order for Life-Sustaining Treatment (POLST, a document that specifies the medical treatments the residents wants to receive during serious illness) form for three out of five sampled residents (Residents 42, 16 and 26). These failures had the potential to lead to the delivery of unnecessary or inappropriate medical services against residents' goals and wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an orderly, comfortable, and homelike environment for one of five sampled residents (Resident 69) when Resident 69's closet door did not latch to remain close. This failure had the potential to result for Resident 69's decreased sense of well-being and an uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment and care screening tool) assessment was coded accurately for weight gain for one of 10 sampled residents (Resident 78). This failure compromised the facility's ability to develop and implement a resident-centered care plan and interventions for the resident's severe unplanned weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions for one of 20 sampled residents (Resident 13) regarding supervision with ambulation, continue encouraging to wear shirts or gowns while not in rooms, and ensure resident have non-skid socks/shoes while walking in the hallways . This failure had the potential to result in residents not receiving the appropriate care necessary to maintain their highest practicable level of health and well-being and result in Resident 13's continued behavioral issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and service in accordance with professional standards of practice for two of six sampled residents (Resident 15 and 92) when: 1. The licensed nurses did not apply a Lidocaine patch (eases pain by numbing the nerves and making them less sensitive to pain) as ordered by the physician; and 2. The licensed nurses stored Resident 92's custom jewelry in a narcotic box (NB, a locked medication compartment inside a medication cart) in the medication cart (MC) 2. These failures had the potential to compromise residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for effective communication when the facility did not provide language assistance or other communication aid and did not develop a baseline care plan to one of three sampled residents (Resident 254) with language barrier (speaking in foreign language). These failures had the potential to affect the psychosocial well-being of Resident 254 and a decline in the activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the fall care plan, provide new intervention, and provide a resident centered care plan interventions to prevent the falls for one of two sampled residents (Resident 6) who was high risk of falling. These failures resulted in Resident 6's four falls since admission and had a potential to result in major injuries (broken bones, joint dislocation, head trauma or even death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure implementation of a comprehensive systematic approach for effective monitoring for one sampled resident (78) who experienced a severe unplanned weight gain of a 9.78% in three months and did not maintain acceptable parameters of nutrition. This failure had the potential to result in additional unintentional weight gain for Resident 78, which could lead to further weight gain and decline in health and nutrition status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for two of two sampled residents (Resident 6 and 10) when: 1. Registered nurse F (RN F) failed to ensure the oxygen was on and at 3 liters per minute (L,metric unit of capacity, P, M) as ordered, when Resident 6's oxygen tubing was transferred from the oxygen concentrator (a medical device that provides a safe source of oxygen-enriched air) to an E-tank (a portable 3-foot-tall aluminum tank that contains oxygen), and staff did not develop a care plan related to Resident 6's oxygen use; and 2. Staff did not post an Oxygen in use/No Smoking sign at Resident 10's room entrance door and staff did not develop a care plan related to Resident 10's oxygen use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted clearly visible in a prominent place that was readily accessible to residents and visitors. This failure had the potential to result in nurse staffing misinformation about resident's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 18) was free from unnecessary psychotropic drugs (medication capable of affecting the mind, emotions, and behavior) when Resident 18's physician order of Lorazepam (used to treat anxiety) as needed (PRN) was not limited to use up to 14 days.

Inspectors wroteBased on observation, interview and document review, the facility failed to comply with Federal and State laws, and regulations when the approval letter for staffing waiver was not posted where visitors and residents could easily read. This failure had the potential to result in nurse staffing misinformation about resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from misappropriation of property (unauthorized purchases from another person's account or using someone else's property) when the housekeeper (HK) cashed out Resident 1's check without Resident 1's permission. This failure compromised the resident's financial security and violated resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation and report for nine of 11 residents (Residents 7, 8, 9, 10, 11, 12, 1, 3, and 4). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incidents and could have compromised the residents' safety.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse involving two of two sampled residents (1 and 2) to the appropriate agencies, including the State Survey Agency. This failure to report potentially compromised residents' safety in the facility and violated mandated reporting requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate individual needs to ensure resident with the same gender shared bathroom, for 34 out of 92 residents (Residents 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33, and 34). This failure had the potential to negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for the Corona Virus 19 precaution (guidelines recommended by the Centers for Disease Control and Prevention for reducing the risk of the Corona Virus 19 [COVID-19, a respiratory illness that can spread from person to person] infection) for residents and staff when staff did not wear appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) for COVID-19 positive confirmed resident and COVID-19 exposed (having contact or close contact to an individual with confirmed or suspected COVID-19) resident (Residents 1 and 2). This failure had the potential to spread COVID-19 throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit an investigation summary regarding an alleged abuse incident that occurred between two of three sampled residents (Residents 2 and 3). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety.

Inspectors wroteBased on interview and record review, the facility failed to implement their antibiotic stewardship program (program intended to prevent overuse of antibiotics) for one of three sample residents (Resident 1). Resident 1 received a course of antibiotics (medication used to treat bacterial infections) for a urinary tract infection (UTI) but did not meet all the criteria that needed to be present for antibiotic use. The facility also failed to inform the physician that Resident 1 did not meet the criteria. These failures had the potential to increase the prevalence of multi-drug resistant organisms in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 21 sampled residents (Resident 15, 46, and 76) and one non-sampled resident (Resident 6) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions and behavior) when: 1. For Resident 15, there was no trial reduction ( tapering the dosage) for psychotropic medication use. 2. For Resident 46, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication was limited to 14 days 3. For Resident 6, the facility failed to monitor specific targeted behaviors for psychotropic medication use. 4. For Resident 76, the facility failed to monitor specific targeted behaviors for psychotropic medication use. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 91 out 96 residents who received food from the kitchen when: 1. Freezer door handle was broken; 2. Expired items were stored in dry food storage room; and 3. Undesignated staff entered in the kitchen. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross-contaminate food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the residents eating at the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure residents' food was stored in a safe and sanitary manner for 91 out 96 residents, when refrigerator designated for residents had foods that were not properly stored and labeled. This failure had the potential for food borne illness.

Inspectors wrote3. Review of Resident 4's admission Record indicated she was admitted to the facility on [DATE] with pneumonitis (inflammation of lung tissue) diagnosis. Review of Resident 4's physician order, dated 1/30/23, indicated she had an order for ipratropium-albuterol (drugs work by relaxing the muscles around the airways so that they open up and the person can breathe more easily) 20-100 micrograms (mcg, a metric unit of mass) solution 3 milliliters (ml, a metric unit of volume) inhale orally every 6 hours as needed for short of breath or wheezing (a high-pitched whistling sound made while breathing). During an observation and interview with licensed vocational nurse B (LVN B) on 4/3/23 at 2:11 p.m., Resident 4's nebulizer ( a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) mask and tubing were undated. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify residents' representatives and families of a confirmed COVID-19 (a respiratory disease caused by a virus which can result in severe illness and death) when four out of 96 residents (Residents 37, 241, 296, and 298) who had positive COVID-19 test result on 4/8/23 and notifications were not sent out until 4/10/23. This failure resulted in residents' representatives and families not receiving timely notification regarding the status and impact of COVID-19 in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for one of three residents (Resident 46) when staff provided feeding assistance while standing. This failure had the potential to affect the emotional and psychosocial well-being of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident call-light equipment was accessible for two of 96 residents (Residents 74 and 81), when the call-light button for both residents was not within reach. This failure had the potential of harm or a decrease in these residents' well-being in the case of an emergency, and they not being able to call for help.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 21 residents (Residents 18 and 89) had been inquired about having an Advance Directive (AD, a written form which indicated your instructions about your own health care), when no form was found, nor any indication of an AD was documented. This failure had the potential of these residents becoming incapacitated and them not receiving the care they would want or not want.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence of documentation regarding the action, progress, and resolution of a complaint/grievance regarding missing glasses reported by Resident 89's family member (FM). This failure resulted in Resident 89's complaint not resolved.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prevention policy by failing to report one of three abuse allegations immediately and failing to screen certified nursing assistant K (CNA K) for criminal background. These failures had the potential to put the residents at risk for elder abuse and further abuse.

Inspectors wroteBased on interview and record review, facility failed to develop baseline care plans for two of 21 sampled residents (Resident 37 and 49) within 48 hours of admission to the facility. This deficient practices of not identifying individualized goals had the potential to negatively affect Resident 37 and 49 abilities to achieve their highest practicable physical, mental, and psychosocial well-being and their continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services for three of 21 residents (48, 76, and 300) when: 1. Licensed nurses did not follow the physician's orders for pain medication based on the residents' pain level for Residents 48 and 76; 2. Licensed nurses did not follow ordered parameters for blood pressure medication for Resident 76; and 3. One medication was administered not in accordance with the physician's order for Resident 300. These failures had the potential to affect the residents' care and could jeopardize their health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a communication device provided to two of 21 sampled Residents (Residents 9 and 37) who spoke in their non-English language. This failure had the potential for Residents 9 and 37 not to understand and carry out activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained free from accident hazards for three residents (Resident 10, 46, and 240) when Oxygen In Use signs were not posted in their rooms while receiving oxygen therapy; and an electrical cord was left in Resident 46's occupied bed. These failures had the potential to result in serious injury to the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out 21 residents (Resident 295) received pain medication upon request when Resident 295 received her pain medication more than 1 hour after her request. This has the potential for physical harm with the resident due to pain and discomfort. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis services consistent with professional standards and to ensure staff had coordinated a resident's care with the dialysis facility for one of two residents (Resident 297) who received hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e. salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Resident 297 dialysis communication records (DCR) were blank and not completed, and 2. Resident 297 physician order, treatment administration record (TAR) did not reflect the dialysis access site for necessary precautions. These deficient practices had the potential for the resident to be inadequately assessed and be at risk for complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and timely dispensing of medications to meet the needs of residents; accurate or effective accountability and storage of controlled substance (CS, drugs with high potential for abuse or addiction) medications; and accurate administration of medications when: 1. One medication in the automated dispensing unit (ADU, a computerized unit for the storage and dispensing of medication) was not refilled timely; 2. One CS medication was stored in the medication cart without daily accounting by the nursing staff; and 3. Resident 190 was administered medications with drug-drug interaction. These deficient practices had the potential for medications being unavailable for use; loss/abuse and unaccountability of CS medications; and inaccurate administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication administration and storage, and labeling of medications for five out 21 residents when: 1. Expired or discontinued medications were not put away; 2. Three nasal sprays did not have resident-specific labeling on each container; 3. An eye drop medication was stored and being used past its expiration date; 4. Resident 30's medications were left on her overbed table unattended; 5. Resident 42 had one opened small packet of A&D next to her drinking glass; 6. Resident 3's room window had used calmoseptine ointment tube that was left unattended. These deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their expiration date; medication errors due to medications not being labeled; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required rehabilitative services for one of 21 residents (Resident 89) when physical and occupational therapy treatments were not provided as ordered for Resident 89. This failure had the potential for Resident 89 not to attain, maintain or restore her highest practicable level of physical function and well-being.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was prepared and served under sanitary conditions when: 1. [NAME] A used incorrect technique when testing the kitchen sanitizer solution (solution used to disinfect food contact surfaces in the kitchen); and 2. Staff did not completely cover their hair with hair nets in the food preparation area of the kitchen. These failures had the potential to cause food contamination and spread foodborne illness (illness resulting from contaminated food) to residents who received their food from the kitchen (80 of 83 residents).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were followed when the following were identified: 1. Droplet precautions were not followed for two (Residents 50 and 284) out of two sampled residents that were coughing. 2. A urinary catheter drainage bag was placed above the bladder for one (Resident 284), out of two sampled residents reviewed for urinary catheters. 3. A blood pressure cuff was not cleaned after use. 4. Hand hygiene was not performed after administration of a medication. These failures had the potential to cause infection in a vulnerable population.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dignity for one out of 18 sampled residents (Resident 14), when the facility failed to provide privacy during cares. This failure resulted in the resident, who was partially uncovered, being visible to anybody walking by his room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 18 sampled residents (Resident 14), preferences for getting up out of bed were met. This failure resulted in the Resident spending most of his time in bed and in his room, alone.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided according to professional nursing standards for one of 18 residents (Resident 31) when licensed vocational nurse E (LVN E) did not use the proper procedure for testing the blood sugar (a procedure performed by puncturing a person's finger with a lancet [a type of needle] to collect blood for testing sugar levels). This failure had the potential to affect the accuracy of blood testing and could cause harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to perform initial pressure ulcer (damage to the skin or underlying tissue as a result of prolonged pressure) measurements and failed to provide pressure ulcer treatments for one of six sampled residents (Resident 183). These failures had the potential to cause worsening in Resident 183's pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate monitoring for safety for one of one sampled resident (Resident 12) when the alarm bracelet that was attached to the resident. This failure had the potential for the alarm system to not work and increased the risk for elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper placement of the gastrostomy tube (G-tube, a tube placed directly into the stomach through the abdomen that delivers food, fluids, and medications) for one of one resident (Resident 50). This failure had the potential to cause harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide social services related to podiatry (the care and treatment of the foot) for one of 18 residents (Resident 21). This failure had the potential to result in discomfort for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate provision of pharmaceutical services for one of two intravenous emergency kits (IV E-kit, a storage of emergency medications that are administered directly into the vein and supplies used to deliver the medications through the vein). This failure had the potential to result in the delay of treatment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to monitor for psychotropic medication (medication capable of affecting the mind, emotions, and behavior) side effects and target behaviors (behavior intended to be changed by the medication) for one of five sampled residents (Resident 183). These failures had the potential to compromise the facility's ability to identify harmful effects from the medications and to monitor the effectiveness of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe and secure storage of medications in one of two medication rooms (Med Room H) and for one of four medication carts (Med Cart I) when: 1. For Med Room H, an expired vial of Aplisol (a medication classified as a tuberculin test used to test a person for tuberculosis [an infection in the lung]) was stored in the medication refrigerator. 2. For Med Cart I, the cart was unlocked, with a drawer open, and medications were on top of the cart. These failures had the potential to result in harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the laboratory services as ordered by the physician for one of 18 sampled residents (Resident 8). This failure had the potential for the resident not to be adequately monitored for changes in condition in order to provide necessary treatment.