The Beach Post-Acute

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled residents, Resident (5) was permitted to return to the facility. The facility failed to:1. Readmit Resident 1 to the facility after Resident 5 was evaluated and cleared by general acute care hospital (IGACH) to return to the facility on [DATE].2. Implement facility's policy and procedure (P&P) titled, Bed-Holds (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) and Returns, dated 10/2022, which indicated residents who seek to return to the facility after the state bed-hold period has expired are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide supervision and assistance to prevent accidents for one of one residents reviewed for falls (Resident 1). The facility failed to:1. Ensure Resident 1 who was assessed as high fall risk and needs substantial/ maximal assistance with ambulation received assistance during ambulation on 3/19/2026 and 3/21/2026. This failure resulted in two unwitnessed falls in the hallway, including one fall causing a right elbow laceration, and placed Resident 1 at further risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) did not miss her hemodialysis ([HD] a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatments as ordered and failed to implement Resident 1's care plan which included monitoring Resident 1 for changes in level of consciousness, abnormal vital signs (essential measurements taken by the healthcare team providers to check the body's most basic and life sustaining functions), heart and lung sounds, edema (swelling caused by excess fluid building up in the body's tissues). These failures resulted in Resident 1 presenting to the dialysis center on 2/16/2026 with facial and generalized body edema. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was experiencing pain, pain level (an eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) was accurately documented by Licensed Vocational Nurse (LVN) 1. This deficient practice resulted in Resident 1's pain level not being identified and had the potential for delayed pain relief and impaired communication among facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they were free from roaches. This deficient practice resulted in a report of roaches in one of three sampled residents' (Resident 1) room, and observations of live and dead roaches in the facility's staff breakroom. This deficient practice had the potential for a roach infestation to occur affecting residents' health and wellbeing.

Inspectors wroteBased on observation and interview, the facility failed to maintain and observe infection control practices by failing to:1. Ensure Certified Nurse Assistant (CNA) 2 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with fixing linens for Resident 41 which required direct contact with Resident 41 who was on Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms {microorganisms, predominantly bacteria, that are resistant to one of more classes of antimicrobial agents}).2. Ensure the oxygen tubing was changed and dated for Resident 42.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term) for one of three residents (Resident 63). This failure had the potential to result in an inappropriate placement and delay of services needed for Resident 63.

Inspectors wroteBased on interview and record review, the facility failed to ensure an annual competency assessment (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks for one of three employees (Registered Nurse Supervisor) were performed every year. This deficient practice had the potential for the facility not able to assess the skills, knowledge, training, and certification necessary to provide nursing services to assure resident safety and adequate resident care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure medications removed from the emergency kit (E Kit-collection of different types of medications in a small box for emergency use supplied by pharmacy to health care organizations) were entered in the communication form and promptly replaced. Augmentin ( a combination of antibiotic that contains two active ingredients: amoxicillin (the primary germ-fighter) and clavulanic acid 125 milligram (mg-unit of measurement) removed from the E-kit (date and time unknown) and Keflex 250 mg (antibiotic use to kill a wide range of bacteria), medications removed from the emergency kit (E Kit-collection of different types of medications in a small box for emergency use supplied by pharmacy to health care organizations) on [DATE] at 1:30 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that a binding arbitration agreement (out-of-court process where a neutral third party hears a dispute and makes a final, legally binding decision) was explained in a form and manner that the resident's representative ([RR]- an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident) could understand prior to obtaining a signature for one of three resident's (Resident 15). This failure had the potential to result in the resident or resident representative unknowingly waiving the right to pursue disputes through the judicial system, thereby limiting legal rights and protections.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide implement post fall interventions for one of three sample residents (Resident 1). Facility failed to: 1. Ensure Resident 1's bed was maintained in the lowest position to help prevent additional falls. This deficient practice placed Resident 1, identified as a fall risk, at increased risk for further falls and potential injury.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of three sampled residents (Resident 1) was treated with dignity and respect during personal care. Certified Nursing Assistant (CNA 1) used derogatory and offensive language toward Resident 1, including statements such as It smells bad and stinkyThis failure resulted in Resident 1 feeling humiliated, insulted, and emotionally distressed. The resident reported staying awake all night due to the incident on 11/29/2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure the following for two of five sampled residents (Resident 1 and Resident 5): 1. Failed to ensure Resident 1 did not develop a Moisture Associated Skin Damage (MASD: skin inflammation caused by prolonged exposure to various sources of moisture such as urine and stool) to her peri-area (region between the buttocks and female reproductive area). 2. Failed to ensure Resident 1's family was able to contact Resident 1 via telephone while residing in the facility. 3. Failed to address ongoing concerns expressed in written grievances for answering call lights for Resident 1 and Resident 5. A. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one out of four sampled residents (Resident 2) received care and services to promote wound healing and to prevent worsening pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from occurring by failing to implement interventions such as a special low air-loss mattress (designed to prevent pressure injuries, treat pressure injuries) and vitamin supplements such as zinc (mineral that plays a crucial role in numerous bodily functions, including immune system support and wound healing), vitamin C (form protein called collagen to make skin and blood vessels), and a multivitamin (dietary supplement that provides foundational support for daily nutritional needs that is not taken through diet) to promote wound healing for Resident 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician and Responsible Party (RP) for one of four sampled residents (Resident 1), who had a history of gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum), anemia (when the blood doesn ' t have enough healthy red blood cells and hemoglobin [a protein in the red blood cells that carries oxygen) to carry oxygen all through the body], and a low hemoglobin, were notified when Resident 1 refused to have his blood drawn in order to obtain a Complete Blood Count ([CBC] a common blood test that measures red blood cells {specialized cells in the blood that play a crucial role in transporting oxygen throughout the body}, white blood cells {a type of blood cell that play a crucial role in the body ' s immune system}, platelets {a tiny disc shaped pieces of cells in the [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly identify and intervene to ensure Resident 1 received treatment and care in accordance with professional standards and their comprehensive person-centered care plan when two physician's orders for Stat (immediately) laboratory (lab) tests were not completed within the required time frame for one of four sampled residents (Resident 1), reviewed for gastrointestinal bleeding ([GI] bleeding anywhere in the digestive tract from the mouth to the rectum). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of three sampled residents, Residents 26,31 and 61 who were receiving hemodialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatments had an emergency dialysis kits (supplies needed to use in an emergency) at bedside, to respond to a potential medical complication, such as bleeding. This failure had the potential to cause a delay in treatment in case of an emergency.

Inspectors wroteBased on observation interview and record review the facility failed to ensure a label of open date and use by dates were placed on an open bag of frozen pancakes and cinnamon rolls. This failure had the potential to expose residents to a food-borne illnesses (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteDuring an interview and record review the facility failed to ensure one out of 18 sampled residents Resident 40 had an updated Pre-admission 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) to reflect Resident 40's medical condition. This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide daily wound care treatment and services for one of five sampled residents (Resident 41) per physician order. This failure had the potential for Resident 41 wound to worsen and delay wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents (Resident 37), received the Restorative Nursing Assistant (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) program as recommended by the physical therapist (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) on 12/12/2024. This failure had the potential to result in range of motion [ROM, full movement potential of a joint (where two bones meet)] decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of 21 sampled residents (Resident 31) received a new upper and lower denture as recommended by Resident 31's dentist on 8/22/2024. This failure had the potential to result in the inability to effectively chew foods, weight loss, and low self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures by not ensuring Licensed Vocational Nurse (LVN) 2 and Certified Nursing Assistant (CNA) 2 perform hand hygiene for one out of five sample residents (Resident 41). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection.

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 21 sampled residents (Resident 42). This failure had the potential to put Resident 42 at risk for antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) and inappropriate use of antibiotic.

Inspectors wroteBased on interview and record review the facility failed to ensure two out of five sampled residents, Residents 42 and 71 were provided with education regarding the risk and benefits of refusing an influenza (Flu-a contagious respiratory illness), pneumonia (PNA-an infection of the lungs), Corona virus-19 (COVID 19 virus that causes fever and cough) vaccine (medication to prevent a particular disease). This failure violated the resident or responsible party's rights to make an informed decision and placed two residents at a higher risk of acquiring and transmitting the influenza, pneumonia and COVID19 to other vulnerable and immunocompromised (a weak immune system) residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan for one of four sampled residents (Resident 1) was revised when Resident 1 had two unwitnessed falls on 10/4/2024 and 10/12/24 and the fall risk assessments on 9/17/2024 and 10/14/2024 identified Resident 1 as high risk for falls. These deficient practices resulted in Resident 1 ' s third unwitnessed fall and subsequent injury on 10/17/2024, when Resident 1 was found on the floor with bleeding on the top of the right side of his head, and later at a General Acute Care Hospital (GACH) was assessed with a subdural hematoma (bleeding in the area between the brain and the skull

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to be free from physical abuse for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 2 hitting Resident 1 on the right knee twice.

Inspectors wroteBased on interview and record review, the facility failed to initiate a person-centered base line care plan for one of two sampled residents (Resident 2) for a behavior of throwing water at her previous roommate. This deficient practice potentially led to Resident 2's agression not being addressed and escalating, compromising other residents' safety. Findings; During a review of the Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (immobility of one side of the body) and hemiparesis (weakness on one side of the body), major depressive disorder (serious mental illness that affects how a person feels and acts), anxiety (unpleasant feeling of fear or uneasiness) disorder, and Type II Diabetes. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure call light was answered in a timely manner for two of two sampled residents (Resident 2 and Resident 4). This deficient practice resulted in Resident 2 and Resident 4 sitting in their urine and feces for a long period of time and has the potential for Resident 2 and Resident 4 to feel embarrassed and humiliated.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled Residents (Residents 2 and 5) and/or their Responsible Parties (RPs) were informed and/or provided a written notice when Resident 2 and 5's rooms were changed. These deficient practices resulted in Residents 2 and 5 and/or their RPs not being given the option to accept or decline the room change and being unaware of and not knowing why Resident 2 and 5's rooms were changed.

Inspectors wroteBased on interview and record review, the facility failed to ensure six of eight sampled residents (Residents 2, 3, 4, 7, 8 and 9) were not verbally abused by Resident 1 after the facility continued to allow residents to reside with Resident 1 despite having a history of threatening and harassing behavior's with his roommates. These deficient practices resulted in Residents 2, 3, 4, 7, 8, and Resident 9 being subjected to Resident 1's verbal abuse, bullying, harassment, and intimidating behavior. These deficient practices had the potential for other resident's admitted to Resident 1's room to suffer verbal abuse.

Inspectors wroteBased on interview, and record review, the facility failed to report four allegations of resident to resident verbal abuse to the California Department of Public Health (CDPH), the State Long Term Care Ombudsman (a public advocate) and local law enforcement, within the regulated time frame of two hours for four of five sampled residents (Resident's 2, 4, 8, and 9). These deficient practices resulted in CDPH not being aware of the abuse allegations that occurred between 2/22/2024 and 8/1/2024 until 8/6/2024 and the inability to investigation the allegations. These deficient practices had the potential for pertinent information to be lost and/or forgotten, more allegations of abuse to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed for one sampled resident (Resident 1), who had a history of verbal abuse, threats, and harassment towards residents who were admitted in his room, to include not allowing admission of other residents to Resident 1's room. This deficient practice resulted in subjecting Residents 2, 3, 4, 8, and 9, who were admitted to Resident 1's room, to Resident 1's known and continued behavior of verbal abuse, threats, and harassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment), located on Station two was locked. This deficient practice resulted in unsecured medications and had the potential for resident's, visitors, and other unauthorized staff to access medications that were left unsecured and out of visual sight of the licensed nurse assigned to the medication cart, which could lead to theft, loss, and/or ingestion of medications not intended for resident's use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was not verbally abused by a Certified Nursing Assistant (CNA 1), when CNA 1, during Resident 1's physical therapy ([PT] a branch of rehabilitative health that uses exercise and equipment to help patients improve their physical abilities) spoke to Resident 1 using a curse word in a loud, angry, and aggressive tone, in a foreign language that Resident 1 happened to understand. This deficient practice resulted in Resident 1's hurt feelings, because he (Resident 1) was making an effort to do the rehabilitation (a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions) exercises and CNA 1 didn't have to curse at him. This deficient practice had the potential for other episodes of verbal abuse to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was conducted following two separate allegations of abuse by one sampled resident (Resident 1). This deficient practice resulted in the facility not identifying other potential residents who may have been affected by abuse and had the potential for the facility not to be able to determine if abuse actually occurred.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor or incapacitated person) with a history of elopement (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision), and assessed as high risk for elopement, did not elope from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 did not elope from the facility twice, the first time on 1/19/2024 and again 4/13/2024. 2. Ensure Resident 1 was not placed in a room with access to an outside patio with a door that opened to an alley. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of resident to resident physical abuse to the California Department of Public Health (CDPH) and the State Long Term Care Ombudsman ([LTC] public advocate) within the regulated time frame of two hours and they failed to report the results of their investigation to CDPH within five working days of the incident for one of two sampled residents (Resident 4). This deficient practice resulted CDPH not being aware of the abuse allegation that occurred 1/2024 until 4/2024 and the inability to investigation the allegation. This deficient practice had the potential for pertinent information to be lost and/or forgotten, more allegations of abuse to go unreported and continued abuse to occur.

Inspectors wroteBased on interview, and record review, the facility's Quality Assessment and Assurance ([QAA] a committee that develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] a committee that takes a systematic, 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 identify Resident 1's elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) on 1/19/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed for one of eight sampled residents (Resident 1), who had a prior history of three strokes. This deficient practice resulted in the care needs of Resident 1, related to prior history of strokes, not being addressed and had the potential for care interventions to not be implemented that would provide Resident 1 with appropriate care to recognize changes in Resident 1 ' s health status, assess, monitor, and/or prevent a recurrence of Resident 1 ' s stroke.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1), who had a change of condition (COC) and was found lethargic (decreased level of consciousness similar to sleepiness, fatigue, or drowsiness) on 2/19/2024 at 1:06 p.m., was continually assessed, monitored and documentation of Resident 1 ' s status was completed. This deficient practice resulted in Resident 1 ' s medical status being unknown by nursing staff from 1:06 p.m. through 5:39 p.m., on 2/19/2024 (four hours and 30 minutes after Resident 1 was assessed as lethargic), no assessment conducted to determine the cause of Resident 1 ' s lethargy and/or as a baseline assessment, such as a blood sugar (b/s) check and neurological assessment (an assessments to identify if there is a change to the resident ' s level of consciousness).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was admitted to the facility for pain management, from a General Acute Care Hospital (GACH) following two spinal fusion (a surgical procedure to connect two or more bones in the lower part of the spine) surgeries, was medicated to control the pain for one of five sampled residents (Resident 1). The facility failed to: 1. Provide Dilaudid (a narcotic medication used to treat moderate to severe pain), for approximately six hours, to Resident 1 who complained of a pain level of 10 out 10 on a 0-10 pain rating scale (where zero= no pain and 10= is the worst pain possible). 2. Follow up with the pharmacy to confirm the pharmacy received the fax order for Dilaudid. 3. [...]

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 implement corrective action from their recent re-recertification survey (12/22/2023) focused on monitoring, treating, and evaluating residents' pain. [...]

Inspectors wroteBased on interview, and record review, the facility failed to sufficiently train one of four licensed nurses, Licensed Vocational Nurse 1 (LVN 1), regarding pain management when LVN 1: 1. Failed to monitor, assess, and document interventions provided to Resident 1 to alleviate the pain, when Resident 1 complained of 10/10 pain. 2. Failed to access the medications in the emergency medication kit (E-Kit, medication kit which contains a small supply of medication that can be dispensed when the medication is not available from the pharmacy) because of lack of knowledge regarding when to use the E-Kit, how to access the medications and the protocol/procedure necessary to obtain the medications from the E-kit. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 2 (LVN 2) administered medication ([Lenalidomide] a medication used to treat cancer) on time, to one of two sampled residents (Resident 2) when LVN 2 administered Lenalidomide to Resident 2 at 11:28 a.m., instead of 9 a.m., as prescribed and no later than 10 a.m. This deficient practice resulted in Resident 2 receiving Lenalidomide two hours and 30 minutes after the ordered administration time and one hours and 30 minutes after the accepted administration time, which had the potential for mismanagement of Resident 1's medication regimen. Findings During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm of the brain (brain cancer). [...]

Inspectors wroteBased on the observation, interview and record review, the facility failed to follow the food preference for one sampled resident (Resident 2) when they served him rice and chicken for lunch when his tray card indicated Resident 2 disliked rice and chicken breast. This deficient practice resulted in Resident 1 purchasing his own food and had the potential for Resident 1 to go without food and potentially lose weight.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control measures for 0ne sampled residents (Resident 2) when Licensed Vocational Nurse 2 (LVN 2) administered Tramadol 1 tablet (a pain medication) to Resident 2 after the tablet fell onto the top of a dirty medication cart. This deficient practice resulted in Resident 2 ingesting medication that was potentially contaminated and had the potential to lead to health related issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment for two of eight sampled residents (Resident 383 and Resident 183) who were identified high risk for fall, when Resident 383's and 183's bed was not in the lowest position and one of eight sampled residents (Resident 51) was at the smoking area without supervision and with unsafe keeping of smoking materials (cigarette and lighter). This deficient practice had the potential for Resident 383 and 183 to sustain an injury due to a fall and Resident 51 to accidently burn while smoking.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure all food items stored in the kitchen refrigerators were labeled and dated and failed to remove expired foods from the refrigerator. These deficient practices could expose residents to harmful bacteria growth, leading to foodborne illness for 83 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility staff failed to perform hand hygiene while administrating medication for one of eight sampled resident (Resident 27) and ensure for one of eight sampled residents (Resident 218) 's indwelling catheter (also known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor and Resident 218's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was not on the floor, improperly stored, and undated. These deficient practices placed Resident 27 and 218 at risk for contracting infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dignity to one of eight sampled residents (Resident 218), when Resident 218 urine collection bag was not covered with a dignity or privacy bag and the bag visible to other residents and visitors. This failure resulted in Resident 218's rights to dignity and privacy being violated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure reasonable accommodation to meet the residents needs when the residents' call light was out of reach for three of eight sampled residents (Resident 41, 218, and 46). This deficient practice had the potential to negatively impact the psychosocial well-being of the residents or result in delayed provision of care or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR resident screening prior to admission, to determine if the person has, or is suspected of having, a mental illness) screening was completed for Resident 64. This deficient practice had the potential for Resident 64 had the potential for not receiving the necessary and appropriate behavioral treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to create and update a patient focused care plan to address fluid restrictions and significant weight gain for one of six sampled residents (Resident 68). This deficit practice resulted in Resident 68 inaccurately being monitored for a fluid restriction of 1.5 liters (L, a unit of measurement of volume) and placed Resident 68 at risk for increased weight gain and fluid overload (too much fluid in the body).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 18 residents (Resident 62) was not left in a wet diaper which resulted in moisture associated skin damage ([MASD] skin damage from exposure to moisture for long periods of time). This failure resulted in Resident 62 developing MASD to his peri-anal (the skin around the anus), and groin area.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and follow the physician's order for fluid restrictions for one out of six sampled residents (Resident 68). This deficient practice had the potential for Resident 68 to experience worsening hyponatremia (low salt in the body) and develop fluid overload (too much fluid in the body).

Inspectors wroteBased on observation, interview and record review, the facility failed to properly assess and manage pain for one of six sampled residents (Resident 75). The deficient practice resulted in Resident 75 experiencing uncontrolled pain.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure that the medication room temperature was consistently monitored and recorded in a Room Temperature Log to ensure a safe temperature range for medication storage. This deficient practice had the potential to harm residents due to the potential loss of strength and effectiveness of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three resident's (Resident 62) family representative understood the arbitration agreement (a document that settles any disputes between two parties through binding arbitration, a dispute resolution mechanism that is out of the court system. This failure resulted in a resident (Resident 62) entering into an agreement for binding arbitration (the process of resolving a dispute outside of the court system by using a neutral third party), without fully understanding what they were signing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who tested positive for COVID-19 (Coronavirus disease -a contagious respiratory infectious illness) on 11/2/2023 and had a change of condition (COC) of shortness of breath and lethargy (condition of deep and lasting drowsiness from which the person can be aroused only with difficulty and temporarily) on 11/6/2023, was provided care. The facility failed to: 1. Ensure Resident 1 was assessed, monitored, and had vital signs (VS- measurements of the body's most basic functions temperature, pulse rate, respiration rate [rate of breathing] and blood pressure)including oxygen saturation ([O2 sat] blood oxygen level) checked every shift as ordered by the physician. 2. [...]

Inspectors wroteBased on interview and record review, for one of six sampled residents (Resident 1), the facility failed to: 1. Ensure Resident 1 was treated with respect when two Certified Nurse Assistants (CNA), CNA 3 and CNA 4, was speaking hostile (aggressive) and rudely (impolite, insulting) at Resident 1 and did not provide Resident 1 the opportunity to express herself in a language (spanish) she can fluently speak. 2. Ensure Resident 1, who speaks spanish, was offered, and provided translation services or a spanish-speaking staff to assist Resident 1 in making herself understood and her needs known. [...]