Sunset Villa Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 1) who's room was changed, received advance written notice including the reason for the room change, exercised his right to refuse the room change, had the opportunity to sign the room-change notice, and was provided a copy of the notice for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not being given the option to accept or decline the room change and resulted in Resident 1 feeling frustrated, irritated, and disappointed after the room change.

Inspectors wroteBased on interview, and record review, the facility's staff failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of three sampled residents (Resident 1), when Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 1, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), found Resident 1 unresponsive (a person is unconscious and fails to react to any external stimulation), not breathing and without a pulse on [DATE] at 12:21 a.m. In addition, seven of eight staff who were CPR certified (Licensed Vocational Nurse [LVN] 1, LVN 3, LVN 4, LVN 5, Certified Nursing Assistant [CNA] 2, CNA 3, and CNA 4) did not initiate or assist in CPR after a code blue was called for Resident 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to notify the physician for one of three sampled residents (Resident 1) when Resident 1's renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) scheduled days were changed. As a result, Resident 1's scheduled dialysis days were changed without Resident 1's physician being made aware. This deficient practice placed Resident 1 at risk for worsening symptoms associated with end stage renal disease ([ESRD] irreversible kidney failure).

Inspectors wroteBased on interview, and record review, the facility failed to develop a care plan that addressed the root cause (falling asleep) of Resident 1's previous falls on [DATE] and [DATE] for one of three sampled residents (Resident 1), who was assessed as a high fall risk. This failure resulted in Resident 1's continued falls on [DATE] and [DATE] after her drowsiness/falling asleep was not addressed following falls on [DATE] and again on [DATE], which possibly contributed to her death on [DATE], when approximately 48 minutes after falling asleep and falling from her bed, Resident 1 was found unresponsive and expired on [DATE] at 12:52 a.m.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure crash carts (a mobile cart stocked with life saving equipment that staff use during emergencies, such as when a patient stops breathing or their heart stops) located at multiple nursing stations were stocked per the Emergency Crash Cart Checklist, the crash carts were easily accessible to staff in the event of an emergent event, and the POLST ([Physician Orders for Life-Sustaining Treatment] a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was easily identifiable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled resident's (Resident 2) call light (device that allows residents to request assistance from nursing staff) was accessible and within reach. This failure resulted in Resident 2 being unable to summon staff for needed assistance and had the potential to result in delayed response, unsafe attempts to self transfer, and falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure an outside activity provider, who was contracted by the facility to provide activity's to residents', was monitored by the facility to ensure the activity provider did not videotape six out of sixteen residents (Residents 6, 10, 11, 12 13, and 14) without the resident's and/or their representative's consent and the outside activity provider did not include in their program disparaging (criticizing, belittling, or undervaluing someone, often in a way that shows a lack of respect or aims to diminish their reputation) remarks towards the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. For Residents 24 and Resident 123, manufacturer's specification for dosing diclofenac (for pain relief) topical gel for application was followed. This deficient practice could have resulted in either an overdose or underdose of the topical pain medication diclofenac, potentially leading Resident 24 and Resident 123 to experience adverse reactions (unwanted or harmful effects from a medicine) or inadequate pain relief.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:a. Ensure dietary staff were wearing hair restraints appropriately while working in the kitchen.b. Maintain the ice machine in a sanitary condition to prevent contamination of consumable ice.c. Ensure proper hand hygiene and glove use during food preparation to prevent cross contamination. These failures had the potential to result in contamination of food and ice, placing residents at risk for foodborne illnesses (an illness that comes from eating contaminated food) including Legionella (type of bacteria found in water environments).

Inspectors wroteBased on interview and record review the facility failed to provide documented evidence of for 32 out of 32 licensed practitioners, COVID-19 (a highly contagious respiratory disease) vaccination (medications used to prevent diseases usually given by injection or by mouth) status, provision of education on benefits and potential side effects for 32 out of 32 licensed practitioners for the 2025 to 2026 COVID-19 vaccine. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of eight sampled residents (Resident 29 and 76) were treated with respect and dignity by failing to:a. Cover Resident 29's back during ambulation.b. Provide scheduled showers for Resident 76. These deficient practices had the potential to have a negative impact on the psychosocial well-being of the residents and affect their self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing assessment and evaluation for the continued use of a sensor pad alarm (a device designed to detect moisture or movement, alerting someone immediately) for one of one sample resident (Resident 142). This failure has the potential to result in restricting the residents' movement, loss of dignity, sleep disturbance due to the sound of alarm, confusion, fear, agitation, and anxiety or irritation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 14) was free of unnecessary psychotropic medications (any drug that affects brain activity related to mental processes and behavior) by failing to:1. Ensure Resident 14's Lexapro (a prescription medication that helps keep more serotonin available in the brain which helps improve mood, anxiety (constantly feeling worried and nervous), and emotional stability) order had the correct indication for anxiety as indicated by the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for two of four sampled residents (Resident 17 and Resident 40) when:a. Resident 17 was taking an anti-anxiety medication (medication to treat symptoms such as feelings of fear, dread, uneasiness, and muscle tightness) for anxiety (constantly feeling worried and nervous).b. Resident 40 was taking an anti-coagulant medication (medications that prevent harmful blood clots from forming) for diagnosis of atrial fibrillation (irregular heart rate that can cause poor blood flow). This deficient practice had the potential to result in inaccurate assessment and services for the residents due to the inaccurate MDS assessment and care screening tool practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Residents 14 and Resident 19) Preadmission Screening and Resident Review (PASARR- a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) were reassessed appropriately by:1. Failing to ensure a PASARR level 1 resident review screening was resubmitted for Resident 14's and Resident 19's new mental health diagnosis and medications. This deficient practice placed Resident 14 and Resident 19 at risk of not receiving necessary care and services needed for mental illness or developmental disability.

Inspectors wroteBased on interview and record review, the facility failed to ensure a person-centered care plan was implemented for two of four sampled residents (Resident 17 and Resident 1) when:a. Resident 17 who was receiving a psychotropic medication (a medication that alters chemical levels in the brain, affecting mood, perception, thoughts, and behavior). b. addressing Resident 1's arteriovenous (AV) (connection or interaction between arteries and veins) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access). These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 17 and Resident 1 to prevent them from achieving their highest practical well-being.

Inspectors wroteThe facility failed to ensure adequate supervision to prevent one of one sampled resident (Resident 27) from accessing and consuming food from another resident (Resident 25). This failure had the potential to result in choking, allergic reaction, consumption of food inconsistent with the resident's prescribed diet and exposure to contaminated food.

Inspectors wroteBased on interview and record review the facility failed to ensure proper catheter management for three of three sampled residents (Resident 10, 50, and 184) with an indwelling catheter (flexible tube inserted into the bladder to drain urine) by failing to: a. Clean the catheter, assess urine for signs and symptoms of infection, and monitor the urine output for Resident 10 and 184. b. Ensure Resident 50 had an order for a suprapubic catheter (a tube inserted through the lower abdomen directly into the bladder to drain urine) and monitoring for a urinary tract infection ([UTI]- an infection in the bladder/urinary tract) were in place. These deficient practices had the potential for the residents to develop an UTI and result in fever, pain or blood in the urine.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide three of three hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents (Resident 1, 6, and 103) with dialysis care and services consistent with standards of practice when the facility failed to:a. Ensure a blood pressure (measures the force in arteries when heart beats and rests) reading was not obtained on Resident 6 and 103's left upper extremity where the arteriovenous (AV) shunt (a direct connection between an artery and a vein, bypassing the capillary network, which can be natural or surgically created for medical access) was located. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (1) expired medication, fluticasone furoate Ellipta (a once-daily inhaled corticosteroid used for long-term maintenance treatment of asthma, which lowers swelling and helps the body fight inflammation) oral inhaler was not stored in one out of four (4) sampled medication carts (Medcart) 2A on Station 2 and administered to a resident (Resident 79) two times after expiration on [DATE] and [DATE]. These deficient practices had the potential for loss of potency of the medication and for Resident 79 to receive ineffective medication necessary to help maintain and/or improve the resident's breathing.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a recommendation for an ultrasound ([US] equipment used to produce high-frequency sound waves that travel deep into tissue and create therapeutic heat) of the right thyroid nodule ( unusual lump (growth) of cells on your thyroid gland [produces hormones and regulate metabolism, energy levels, growth]) for diagnostic testing for one of seven sampled residents (Resident 101). This deficient practice had the potential to delay necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 101) received Restorative Nursing Assistant ([RNA] promotes a resident's ability to adapt and adjust to living independently and safely) services as ordered by the physician. This deficient practice had the potential to delay treatment and services for Resident 101 and placed Resident 101 at higher risk for further decline and weakness.

Inspectors wroteBased on interview and record review the facility failed to obtain consent for an arbitration agreement (legally binding contract where parties agree to resolve disputes through a private arbitrator rather than a public court trial) from the resident representative for one of three sampled residents (Resident 19), who did not have the capacity to make decisions. This failure had the potential to result in the resident signing a legal binding agreement while not comprehending his/her right to access court remedies. During a review of Resident 19's admission Record, the admission Record indicated the facility admitted Resident 19 on 11/14/2001 and was re-admitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by chemical imbalances). [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to identify and implement corrective action of systemic problems identified thereby affecting 173 of 173 residents by failing to:a. Ensure person-centered care plan was initiated and implemented for every resident in the facility.b. Ensure 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) was done in a timely manner. c. Ensure the Minimum Data Set ([MDS], resident assessment tool) was accurate according to the residents' needs and services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policies and procedure (P&P) when:a. The facility failed to provide documented evidence of 32 out of 32 licensed practitioners, Annual Influenza ([Flu] highly contagious respiratory infection) vaccine (medications used to prevent diseases usually given by injection or by mouth) status and the provision of education on benefits and potential side effects and offering of the 2025 to 2026 flu vaccine. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses documented vital signs and nursing interventions when a resident (Resident 1) was coughing up blood, for one of four sampled residents (Resident 1). This deficient practice resulted in missing documentation indicating care that was given to Resident 1 and had the potential for Resident 1's progress during a change of condition to be undetermined and/or unidentified and the provision and/or escalation of his care to be delayed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had poor safety awareness (a resident's inability to recognize physical dangers and follow safety instructions, which puts them at risk for injury - especially during mobility and self-care activities), a history of a falls, and was a moderate risk for falls, was supervised by the nursing staff while seated in her wheelchair. The facility failed to:1. Ensure the nursing staff promptly provided redirection and cueing (the use of verbal, visual, or tactile prompts to guide a resident's behavior or actions in a safe and appropriate manner) to prevent Resident 1 from getting up from her wheelchair unattended.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on a podiatry consultation referral for one of three sampled residents (Resident 1). This failure had the potential to result in a delay in delivery of care and services, and risk for skin breakdown and infection for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 2) with meals that accommodated the resident's food preferences. This failure had the potential to result in decreased meal intake and malnutrition.

Inspectors wroteBased on observation, interview and record review the facility failed to notify one of eight sampled residents (Resident 7's) physician when Resident 7 was observed with multiple open sores on her hands on 7/8/25. This failure had the potential for delayed treatment on Resident 7 multiple open sores and placed Resident 7 at risk for wound infection.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) accurately reflects used of antipsychotic (medications- affecting the chemical messengers in the brain) medications for one of three sampled residents' (Resident 4) This deficient practice had the potential to negatively affect Resident 4's plan of care and delivery of services.

Inspectors wroteBased on interview and record review the facility failed to ensure resident who was assessed at risk for falls, had the resident care plan revised to include the use of non-skid socks for one of three sampled residents ( Resident 2). This deficient practice had the potential to increase the risk of a fall for Resident 2.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1's) who was on Enhanced Barrier precautions (EBP- infection control measures to reduce the spread of multidrug-resistant organisms (MDRO's) for the use of a midline (a long peripheral catheter inserted into a vein) was implemented when toileting Resident 1. This deficient practice placed Resident 1 at risk for possible worsening of her infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents medical records were up to date as per the facility's policy and procedure (P&P) titled,Advance Directive, revised 2/2025, regarding Advance Directives ([AD], a legal document indicating resident preference on end-of-life treatment decisions) for two of six sampled residents (Resident 530). This deficient practice violated the residents' rights to be fully inform of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to implement recommendations from the Level II 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 six sampled residents (Resident 140). This deficient practice had the potential to negatively affect Resident 140's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASRR- a federally mandated program ensuring individuals with mental illness, intellectual/developmental disabilities, or related conditions receive appropriate placement and services) recommendation to obtain a PASARR level II evaluation for one of three sampled residents (Resident 25). This deficient practice had the potential to result in an inappropriate placement and delay of the resident's needed services.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Implment the interventions in Resident 55's care plan to monitor, and document the effectiveness and side effects of seizure medications he was receiving. 2. Develop a comprehesive care plan for Resident 530 a comprehensive care plan for a bed sensor alarm (alarm that triggers if the resident tries to get out of bed) that was placed in her bed. 3. Develop a baseline care plan for a psychotropic (medication that affects the brain)medication for Resident 427. 4. provide bilateral bed bolsters (a long narrow pillow or cushion used to improve bed safety without the use of side rails, preventing patients from rolling too far to the left or right) as indicated in Resident 43's untitled care plan for Falls. 5. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility: 1. Failed to ensure there was documentation on the usage of an Emergency kit (E-Kit, a kit containing a small amount of medication that can be dispensed when the pharmacy services are not available) on a designated log. 2. Failed to receive and review daily activity and discrepancy reports of the Cubex (a computerized system that stores, dispenses, and tracks medications in a healthcare setting) since 10/13/24, or for at least 4 months. These deficient practices had the potential for medication errors, loss and/or diversion (transfer of medication from a lawful to an unlawful channel of distribution or use) of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services were provided and followed up for two of five sampled residents (Resident 9 and Resident 113) as evidenced by: A. Failing to follow up and update Resident 9 and Responsible Party(RP) for the status of Resident 9's denture. B. Failing to follow up on recommended dental services (Resident 113). These failures had the potential to result in Resident 9 and Resident 113 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 530) had a call light that was within reach of the resident who was a high fall risk when the call light was observed on the floor out of reach for the resident. This failure had the potential for Resident 530 to feel frustrated when she could not summon help due to the call light not being within reach, her needs not being met and also delay of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure use of a bed alarm (an alarm with sensors that will alarm when a resident leave or attempt to leave their beds unassisted to help prevent falls by alerting staff) was assessed, monitored and documented for one of three sampled residents (Resident 165). This failure had the potential to result in Resident 165 inhibiting to have quality sleep and restrict the mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment tool) was accurately documented for one of five sampled residents (Resident 140.) This deficient practice had the potential to negatively affect Resident 140's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of six sampled residents (Resident 34) received quarterly Interdisciplinary Team (IDT - a group of medical professionals from different disciplines who work together to help a resident achieve their goals) meetings for one of six sampled residents (Resident 34). This deficient practice had the potential to result in Resident 34 not being informed of their care and have concerns addressed.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of care and ensure one out of 16 sampled residents (Resident 43) who was receiving tube feeding (TF, delivers liquid nutrition through a flexible tube that goes directly into your stomach or small intestine) had the head of bed (HOB) elevated at least 30 degrees while TF was turned on. This deficient practice had the potential for Resident 43 to aspirate (accidental breathing in of food or fluid into the lungs).

Inspectors wroteBased on observation and interview, the facility failed to ensure one of one sampled resident (Resident 77) was provided care and services to maintain good grooming and personal hygiene. This deficient practice had the potential to result in a negative impact on Resident 77's quality of life and self-esteem. During a review of Resident 77's admission record, the admission Record indicated Resident 77 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral infarction (blood flow to the brain is interrupted causing brain cells to die), and Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 43) with history of falls, had bilateral bed bolsters (a long narrow pillow or cushion used to improve bed safety without the use of side rails, preventing patients from rolling too far to the left or right) in place as care planned and recommended by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients). This deficient practice has a potential for Resident 43 at risk for recurring falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to monitor specific target behaviors for a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) for one of two sampled residents (Resident 427). This deficient practice had the potential to result in over use of an antipsychotic medication, without monitoring for the effectiveness and/or ineffective of the medication and can lead to adverse drug reactions. [...]

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) for 172 out of 186 total residents in the facility by not: A. Ensuring food Items were dated, labeled, and discarded before the used by date (expiration dates). B. Ensuring the temperature of a small freezer in dry storage was monitored and documented. C. Ensuring the proper level of the concentration of the quaternary ammonium in sanitization bucket was monitored and maintained. D. Ensuring Dietary Aid (DA) 1 took off her wristwatch that was not covered with gloves. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures by failing to ensure Quality Assurance Nurse (QAN-a nurse who is evaluating nursing practices within an agency and recommending changes for improvement) 1 performed hand hygiene while she was checking lunch trays in dining room. This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors.

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 one of three sampled residents (Resident 164)for prescribed doxycycline (antibiotic used to treat bacterial infections. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics unnecessarily.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of facility employees' screening, education, offering, and current Corona virus disease, ([COVID-19] a contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This deficient practice had the potential to place the facility staff and residents at risk for outcomes such as severe pneumonia (inflammation of lungs that cause difficulty breathing) which could lead to hospitalization due to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to verbally confirm with five of five sampled resident ' s (Residents 1, 2, 3, 4 and 5) primary care physician (PCP) 1 that he was no longer returning to the facility and failed to follow their policy and procedure titled, Choice of Attending Physician, indicating the facility must inform the resident in writing of the name and contact information for his or her attending physician. This failure resulted in the residents being told that the physician was being changed to a new physician and interrupting the consistent continuity of care of the resident ' s previous physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had an unwitnessed fall, did not experience extreme pain for over two hours after she was found on the floor, before care and treatment were rendered, when: 1. Licensed Vocational Nurse 1 (LVN 1) failed to report to Resident 1 ' s physician, that Resident 1 had an unwitnessed fall, so that care instructions including an order for pain medication could be prescribed and administered. 2. LVN 1 failed to conduct a post-fall assessment of Resident 1 to determine if an injury occurred or to determine Resident 1 ' s pain level. 3. [...]

Inspectors wroteBased on interview and record review, the facility to ensure Licensed Vocational Nurse 1 (LVN 1) notified the physician and the Responsible Party (RP) for one out of three sampled residents (Resident 1) when Resident sustained an unwitnessed fall and complained of severe pain. This deficient practice resulted in Resident 1 being found on the floor after sustaining an unwitnessed fall, experiencing unrelieved pain for approximately two hours, and Resident 1 ' s RP and physician being unaware that Resident 1 fell, thus causing a delay in care and/or the inability for Resident 1 ' s physician to prescribe treatment and transfer for a higher level of care in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 1) was competent to care of one of three sampled resident (Resident 1) who sustained an unwitnessed fall, by ensuring LVN 1 was in-serviced on fall assessment, prevention of falls and procedures following a fall, when their Fall Prevention in Long Term Care Part 1: Risk Assessment video was available in 9/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) and/or their responsible party (RP), was informed of the resident ' s transfer to another facility. This failure resulted in violating the residents ' right to make an informed decision regarding the transfer to another facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent unplanned weight loss (a weight loss greater than 5 % in one month) of 24.3 pounds ([lbs.] 18.2 % percent {%}) in 40 days from 3/11/2024 to 4/20/2024 for one of three sampled residents (Resident 1). The facility failed to ensure: a. Staff identified Resident 1's decrease in oral intake (amount of food and water consumed) from 3/16/2024 to 3/27/2024 (a total of 11 days). b. The nursing staff reported a decrease in Resident 1's oral intake to Resident 1's physician (MD 1), when Resident 1 began refusing meals from 3/16/2024 to 4/1/2024 (MD 1 was notified 16 days later). c. Nursing staff followed the facility's P&P titled, Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol and immediately notified physician of any abrupt or persistent change from baseline appetite or food intake. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of six sampled residents (Resident 1) when Resident 1 sustained a fracture (a break in a bone) of the distal right femur (the area of the leg and/or thigh just above the knee joint). This deficient practice resulted in the inability of CDPH to investigate Resident 1's femur fracture in a timely manner and had the potential for facts related to the injury to be forgotten by staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown origin was thoroughly investigated and the conclusion to their investigation reported to the California Department of Public Health (CDPH) for one of six sampled residents (Resident 1) when Resident 1 sustained a fracture (a break in a bone) of the distal right femur (the area of the leg and/or thigh just above the knee joint). This deficient practice resulted in the facility's inability to determine the cause of Resident 1's femur fracture and had the potential for other injuries to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six Certified Nursing Assistants (CNA) 3 had an active State-approved CNA license while providing direct care to residents. This deficient practice had the potential for knowledge and training deficit leading to inadequate resident care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that during the facility ' s pharmaceutical services transition to a new pharmacy provider the residents continued to receive medications as order by the physician without missing any doses and would be free from significant mediation errors for three of six sampled residents (Resident 1, 2 and 3). The facility failed to: 1. Ensure Resident 1, who was prescribed Clonazepam (a control medication in schedule IV [group of medicines has been associated with abuse, misuse and diversion] used to treat anxiety, panic attacks and seizures) 1.0 milligram ([mg] a unit of measurement) for anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness) manifested by severe panic and agitation that interfered with care, did not miss 23 doses of Clonazepam 1 mg from 3/28/2024 through 4/14/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for three of six sampled residents (Residents 1, 2 and 3), when Resident 1, who was prescribed Clonazepam (a control medication in schedule IV [group of medicines has been associated with abuse, misuse and diversion] used to treat anxiety, panic attacks and seizures) for anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness) manifested by severe panic and agitation that interfered with care, did not receive 23 doses of Clonazepam from 3/28/2024 through 4/14/2024, when Resident 2, who was prescribed Risperdal (a medication used to treat schizophrenia, and bipolar disorder) manifested by aggression that may interfere with needed care, did not receive four doses of Risperdal from 4/3/2024 through 4/8/202 and when Resident 3, who was prescribed Seroquel (a medication used to treat [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, a resident, who was receiving nutrition through a gastrostomy tube ([GT] a soft tube surgically inserted through the belly to provide nutrition, hydration and administer medications) did not have severe weight loss of 10.3 percent (%) in a little over one month (42 days) for one of eight sampled residents (Resident 41). The facility failed to: 1. Ensure Resident 41's care plan interventions to provide adequate nutrition were implemented. 2. Ensure the Interdisciplinary Team ([IDT] resident's health care team consisting of various specialties) meetings were held regularly in accordance with the facility policy and procedure (P&P) titled Weight Committee to make recommendations to prevent Resident 41's weight loss. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who was complaining of a right hip pain after sustaining a fall with the right hip fracture, had the pain under control for one of eight sampled residents (Resident 153). The facility failed to: 1. Ensure Resident 153 was accurately assesses for pain level, documented, and re-assessed the resident's pain level after administration of pain medication to evaluate medication effectiveness in relieving pain. 2. Notify the physician Resident 153 did not have a pain relief from Tylenol (medication for mild pain relief) 325 milligrams ([mg] a unit of measurement) two tablets. 3. Ensure the facility's licensed nurses implemented Resident 153's care plan and notified the physician of Resident 153 experiencing unmanageable and intolerable pain. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure storage and distribution of food was done under sanitary and safe conditions for all residents in the facility by failing to: 1. Ensure an employee's water bottle was not stored in the residents' refrigerator in the kitchen. 2. Ensure boxes delivered with resident food were not stored on the floor in the kitchen. These deficient practices had the potential to result in pathogen (germs) exposure to resident and placed residents at risk for developing foodborne illness (illness resulting from contaminated foods, pathogenic bacteria, viruses, or parasites that contaminate food). During an observation and interview on the initial tour on 3/19/2024 at 8:22 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and reasonable accommodations in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by: A. Failing to place the call light within reach for Resident 92. B. Failing to place the call light within reach for Resident 4. C. Failing to speak with respectable manner to Resident 69. D. Failing to provide Resident 117 with a working call light. E. Failing to change Resident 117 in a timely manner after being left wet in urine for hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow through and accurately assess with the Preadmission Screening and Resident Review (PASARR- a comprehensive evaluation that ensures people who have been diagnosed with serious mental illness, intellectual, and/or developmental disabilities are able to live in the most independent settings while receiving the recommended care and interventions to improve their quality of life) level I and level II evaluation for three of four sampled residents (Resident 72, Resident 4, and Resident 92) to determine the facility's ability to provide the special need of the residents. This deficient practice placed Resident 40 and Resident 37 at risk of not receiving the necessary care and services they need.

Inspectors wroteBased on observation, interview and record review the facility failed to: a. Maintain proper storage of drugs and medical equipment used in the provision of care to residents. The facility failed to ensure medications were properly labeled with the opened-on date. This deficient practice had the potential for medications to be administered past the recommended dates rendering them ineffective or potential for negative side effects. b. Ensure medications were secure and inaccessible to unauthorized staff and residents. This deficient practice had the potential for residents, staff and visitors to have access and can ingest medications that could cause clinically significant adverse consequences necessitating hospitalization to stabilize.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance ([QAA] a group which develops and implements appropriate plans of action to correct identified quality deficiencies) committee and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to discuss findings for trends, analysis and recommendations regarding residents' pain management according to the facility's recent re-recertification survey's (3/26/2024) plan of correction. This deficient practice placed the facility at risk to have repeated deficiencies in pain management and potential negative outcomes for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe and practice infection control measures by failing to: A. Ensure Resident 325 's nasal cannula's prongs ( small flexible tube that contains two open prongs intended to sit on the nostril to deliver oxygen) did not touch the floor before applying it to the resident. B. Observe contact isolation precaution (precautions used for disease, germs and infection that are spread by touching the patient and items in the room) during mealtime for Resident 323. C. Prevent, identify, and assess Resident 5, Resident 110, and Resident 269 for scabies( contagious, itchy skin rash caused by a tiny burrowing mite and can spread quickly through close person-to-person contact) D. Ensure Resident 269 who was re-admitted from the General Acute Care Hospital (GACH) with scabies was isolated from other residents. E. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 162) had a completed acknowledgement of advance directives and Physician Orders for Life-Sustaining Treatment (POLST- a medical order that helps give people with serious illness more control over their care during a medical emergency) in their medical records. These failures had the potential for delay of care and treatment or inadvertently missed health care wishes or decisions of the residents during emergency, end of life, and changes in condition.

Inspectors wroteBased on interview and record review, the facility failed to investigate and include a summary of pertinent findings of the investigation for one of one sampled resident (Resident 1) when Resident 1 filed a grievance on 5/13/2024 regarding a Certified Nursing Assistant (CNA) 1 on the night shift. This deficient practice violated Resident 1's right to have his grievance investigated.

Inspectors wroteBased on interview and record review, the facility to report an allegation of abuse to the California Department of Health ([CDPH] the state department responsible for public health in California) within 24 hours, implement the facility's abuse prevention policy and failed to report the results of the abuse investigation within 5 days for one of eight sampled residents (Resident 270). These failures placed Resident 270 at risk for further abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility which is considered their home.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who was a wanderer (a person who walks around aimlessly) and was assessed as a moderate risk for falls, did not sustained right hip fracture (process of breaking or the state of being broken) of the unknow source for one of eight sampled residents (Resident 153). The facility failed to investigate the source of Resident 153's right hip pain to rule out possible abuse. This deficient practice resulted in the cause of Resident 153's right hip fracture and having requiring surgery on 3/12/2024 for a right hip arthroplasty (removal of a broken bone and/or cartilage and replaced with prosthetic components) not being investigated for an injury possibly caused by abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care on one of six sample residents(Resident 61) by : 1. Failing to check and monitor if a podiatry service is needed for Resident 61's toenails who had thick and overgrown toenails. This failure had the potential to cause discomfort and for Resident 61's toenails to cut into the skin due their length.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one five sampled residents (Resident 138) who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency kit at resident's bedside. This failure had the potential for delayed intervention during accidental bleeding on Resident 138.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four nursing staff had the specific competency and skill necessary to care for 169 residents who had full code status ( if a person's heart stopped beating or stopped breathing all resuscitation procedures will be provided to keep them alive) by failing to: 1. Ensure Certified Nursing Assistant (CNA4) and Registered Nurse 1 (RN1) had Basic Life Support (BLS, training to equip healthcare professionals the necessary skills to respond to life-threatening or emergency situations) Certification. 2. Ensure that employees completed a skills competency checklist at the time of hire and annually. These failures had the potential for RN1, CNA 4, and CNA 3 unable to help residents in the facility who are in full code status during a life-threatening situation or when these skills are needed to be applied.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure correct administration of medication as instructed by the manufacturer's label for medication to ensure it was free of significant medication error for one of four sampled residents (Resident 116). Resident 116, had a physicians order for Aspirin (medication used to prevent formation of blood clots) 81 milligrams (mg - a unit of measure of weight) chewable, the Licensed nurse (LVN) # did not follow the route of administration and rather administered the medication with five other different medication to Resident 116 to swallow together at the same time. This deficient practice had the potential to inhibit the correct absorption and effective functioning of the Asprin 81 mg used for prophylaxis (prevention) cerebrovascular accident (CVA - brain tissue damage due to a blood clot) for Resident 116.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light for one of six sampled residents (Resident 152). This deficient practice had the potential to result in delay in meeting the resident's need for assistance and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who had the right below the knee amputation ([BKA] a surgical removal of the area of the leg below the knee) surgical wound, did not develop a pressure injuries ([PI] localized areas of injury that occur when skin and underlying tissue are compressed from pressure) for one of three sampled residents (Resident 1). The facility failed to: 1. Provide care consistent with the facility policies and procedures (P/P) titled Skin assessment, best practice, Pressure Wounds/Skin breakdown clinical protocol, Comprehensive person-centered care plans, and Charting and Documentation and Resident 1 ' s untitled care plans for skin integrity initiated on 11/12/2023, and 11/14/2023 to prevent an avoidable pressure injury. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's rights were maintained for one of three sampled residents (Resident 1) when the facility failed to notify Resident 1 ' s Responsible Party (RP) and primary physician after the Treatment Nurse (TN) assessed a new skin ulcer on Resident 1 ' s right below the knee (BKA-surgical removal of leg below the knee) area on 2/9/2024 and required treatment by the facility ' s wound care consultant (WCC) physician, This deficient practice resulted in a violation of residents ' rights and prevented Resident 1 and Resident 1 ' s family from being involved in Resident 1 ' s plan of care.

Inspectors wroteBased on interview and record review, the facility failed to revise and implement two of three sampled residents' (Resident 1 and Resident 2) care plans after a change of condition was assessed by the nursing staff. The facility failed to; 1. Revise Resident 1 ' s care plan after the Treatment Nurse (TN) 1 assessed a new skin ulcer on Resident 1 ' s right below the knee (BKA-surgical removal of leg below the knee) area on 2/9/2024 and required treatment by the facility ' s wound care consultant (WCC) physician. 2. Ensure the Interdisciplinary Team (IDT-Resident's health care team from different specialties) conducted a meeting to discuss and revise Resident 2 ' s care plans after Resident 2 ' s reported an unwitnessed fall on 2/14/2024. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for the effects of anticoagulants ( medication used to prevent blood from clotting) for one of three sampled residents (Resident 2), by failing to: 1. Thoroughly assess Resident 2 ' s skin for bruising (skin discoloration due to underlying leaking blood vessels) consistent with Resident 2 ' s care plans and physician orders. 2. Implement pharmacist (PharmD) recommendations during the monthly medication regimen review (MRR-review of medications in order to promote positive outcomes and minimize adverse consequences associated with medication) conducted on 2/5/2024. These deficient practices resulted in the following : 1. Resident 2's purplish skin discoloration on Resident 2 ' s left hip not being assessed timely and leading to a delay in care and services. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled resident's (Residents 1) Quetiapine Fumarate (medication used to treat depression [a constant feeling of sadness and loss of interest]) was administered as prescribed. This deficient practice resulted in Resident 1 missing three doses of Quetiapine and had the potential for Resident 1 to exhibit behaviors from missed medications like trouble sleeping, nausea or vomiting.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled resident's (Residents 2) Escitalopram (medication used to treat depression [a constant feeling of sadness and loss of interest) bubble pack (packaging in which the medication is sealed between cardboard backing and clear plastic cover), containing 21 tablets, was not left on the nursing station counter accessible to staff, visitors, and residents. The deficient practice had the potential for Resident 2's Escitalopram tablets to be lost, stolen, and/or consumed by another resident, visitor, or staff.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one of five sampled residents (Resident 4) that Resident 4 did not receive Tamiflu (generic name for Oseltamivir Phosphate an antiviral medication to treat and prevent flu or influenza [acute respiratory infection]) during an Influenza Outbreak as ordered. This failure resulted in Resident 4 not receiving prophylaxis flu treatment for two weeks and had the potential to put the resident's health in jeopardy.

Inspectors wroteBased on interview and record review, the facility failed to ensure Tamiflu (generic name for Oseltamivir Phosphate an antiviral medication to treat and prevent flu or influenza [acute respiratory infection])) for one of five sampled residents (Resident 4), during an Influenza Outbreak (OB), was readily available and administered as the physician ordered. This failure resulted in Resident 4 not receiving prophylaxis flu treatments for two weeks and had the potential to put the resident's health in jeopardy.

Inspectors wroteBased on interview and record review, the facility failed to implement their Covid-19 (highly contagious respiratory infection) policy by: a. failing to test three out of three residents (Resident 3, 4 and 5) on days 3, and 5 (response testing-48 hours after the first negative test and, if negative, again 48 hours after the second negative test) per Centers of Disease Control (CDC) guidelines and guidance provided by Long Beach Public Health when their roommates (Resident 1 and 2) tested positive for Covid-19 on 11/10/2023. b. Failing to conduct response testing for facility staff when Resident 2 tested positive for COVID-19 on 11/10/2023. c. Failing to report the COVID-19 outbreak (a resident who has been in the facility more than seven days and tests positive for Covid-19) to the California Department of Public Health (CDPH) when Resident 2 tested positive for COVID -19 on 11/10/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent physical abuse for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure staff monitored Resident 1's aggressive and physically assaulting behavior due to history of these behavior to prevent Resident 1 to push Resident 2 on the floor. 2. Ensure a plan of care (PC) was developed and implemented for Resident 1's history of aggressive behavior with interventions to prevent Resident 1 from being physically assaultive and push Resident 2 on the floor. 3. Ensure staff followed facility's policy and procedure titled, Resident Supervision and Monitoring by providing intense supervision Resident 1 who had an aggressive and physically assaultive behavior history placing other residents at risk for harm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate an alleged resident-to-resident altercation between two of two residents (Resident 1 and 2) on September 1, 2023, by failing to submit an accurate summary report of the investigation of the alleged abuse. The report inaccurately indicated Resident 1 did not have redness on the forehead and the report inaccurately indicated there was substantial space between their (Resident 1 and 2) beds which made it impossible for Resident 2 to hit Resident 1 with the bed remote. This deficient practice had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse.