The Californian Pasadena Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of three (3) sampled residents (Resident 3 and 4) in accordance with the facility's policy and procedure (P&P) when:On 7/30/2026 and 7/31/2026, facility staff did not ensure Resident 3's lunch meal tray was served within the facility's scheduled mealtimes. 2. On 7/30/2026, Licensed Vocational Nurse 1 (LVN 1) did not ensure Resident 4 was given medication in a private room such as the resident's room and not in the dining room while wearing gloves. These deficient practices have the potential to affect Residents 3 and 4 sense of self-worth and self-esteem, which could negatively impact the residents' emotional and mental well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two sampled residents (Reisdent 2) environment was free from accident hazard when a medicine cup of potassium (electrolyte supplements used to treat or prevent low blood potassium (hypokalemia) was left at Resident 2's bedside and failed to assess Resident 1's ability to self- administer medications. This failure had the potential to result in other residents inadvertently ingesting medication intended for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Restorative Nursing assistant (RNA , Certified Nursing Assistant [CNA] who has extra training to help patients recover lost physical skills, improve mobility, and maintain their independence) had current training and demonstrated competency in the proper use of a gait belt (assistive medical device worn around a person's waist to help caregivers safely support, stabilize, and transfer individuals with mobility or balance challenges ) for resident transfers and / or ambulation. This deficient practice had the potential to place residents at risk for falls, injury, or unsafe transfer or ambulation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately measure the Liquid Whole Eggs with Citric Acid (liquid whole eggs or egg whites in a carton) on 7/31/2026 for one (1) of one sampled resident who received eggs with veggies. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, and weight loss for Resident 1 who received eggs with veggies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food temperatures were checked and documented prior to serving breakfast when the temperature of the frittata and oatmeal were not checked on 07/31/2026. This deficient practice had the potential to place residents at risk for foodborne illness (any sickness caused by eating or drinking contaminated food or beverages) due to food not being maintained at safe temperatures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures to ensure the accurate acquisition and administration of drugs and biologicals to meet the needs of two (2) out of four (4) sampled residents (Residents 1 and 2), in accordance with the facility's policy and procedure (P&P), by failing to: Administer Pregabalin (medication commonly used to treat neuropathy (damage or dysfunction of the nerves) Pregabalin 75 milligram (mg, unit of measurement) capsule for neuropathic pain (nerve pain) in accordance with the physician's order on 7/15/2026. Document in Resident 2's Cefalexin (antibiotic for treating bacterial infections) count sheet that Cefalexin 500 mg capsule for the resident's infection, status post laminectomy (surgery to relieve pressure on a nerve in the spine (back) was administered on 7/15/2026. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that medications were securely stored and properly disposed of by failing to ensure: Two (2) of three (3) medication carts (Med Cart, mobile cart used by nursing staff to store, organized and administer medication to residents) were unlocked and unattended. Discontinued medications were disposed of in accordance with the facility's policies and procedures. Three (3) of 14 emergency kits (E-kit, sealed container that holds a limited supply of emergency medications that can be used immediately while waiting for medication from the pharmacy) were sealed. The Medication refrigerator located in the medication room was locked. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handling and storage of laboratory specimens (a biological sample such as blood, urine, or tissue collected from a patient to undergo testing, analysis, or diagnosis) for one (1) of 1 specimen refrigerator (specialized cooling unit designed for storing temperature-sensitive materials, such as urine. stool, sputum blood or other sample before they are transported to the laboratory for testing to maintain specimen at the proper temperature) by not ensuring that: The specimen refrigerator has a thermometer (an instrument used to measure temperature or temperature changes) to ensure the temperature remains within the accepted range, maintaining the viability of the laboratory specimens stored inside the refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was adequately equipped to allow two (2) of 2 sampled Residents (Residents 3 and 4) to call for staff assistance through a communication system in accordance with the facility's policy by failing to ensure: 1. Resident 3's call light was within resident's reach and call light system produced an audible alert at the nurses' station panel board when activated.2. Resident 4's call light was within resident's reach and call light system produced an audible alert at the nurses' station panel board when activated. These deficient practices had the potential to delay residents' assistance and increase Residents 3 and 4's risk of falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for two (2) of three (3) sampled Residents (Residents 4 and 5), in accordance with the facility's policy by failing to ensure Residents 4 and 5's bed controls were peeling, with exposed wiring This deficient practice had the potential to expose Residents 4 and 5 to injury from malfunctioning or damaged equipment.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized/person-centered care plan (CP) with goals and interventions for one (1) out of three (3) sampled residents (Resident 1) after Resident 1 had a change of condition (CoC) for productive cough and increased secretions on 2/28/2026 in accordance with the facility's policy and procedure (P&P). This deficient practice left Resident 1's productive cough and increased secretions not treated and led to the symptoms becoming worse and potentially led to irreversible conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for two (2) of three (3) sampled residents (Residents 37 and 41) reviewed for environment, by failing to ensure:The television (TV) of Resident 37 was functioning. The curtain in Resident 41's room above the sliding door was fully connected with the end of the curtain hanging down from the curtain rail. These failures have the potential to negatively affect Resident 37's well-being and quality of life and in addition had the potential to cause an unsafe environment for Resident 41 and staff to be placed at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure competencies and skills sets to provide nursing and related services were completed for five (5) of 5 sampled employees in accordance with facility assessment and facility's policy and procedures (P&P). This deficient practice had the potential to cause an increased risk for improper resident assessments, and inadequate documentation which could negatively impact the quality of care to the residents. Cross referenced with 755Findings:During a concurrent review and interview on 2/19/2026 at 10:43 AM with Director of Staff Development (DSD), Certified Nurse Assistant 3's (CNA 3) employee records were reviewed. DSD stated CNA 3 was hired on 9/18/2017. DSD stated CNA 3 did not have documented evidence of completed skills competency evaluation upon hire and annually. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices in accordance with the facility's policy and procedure (P&P) by failing to ensure: Three (3) individually prepared ice cream bowls were labeled with use by date. An open gallon container of ice cream, opened on 2/18/2026 has a use by date of 6 months after open date. Kitchen freezer 1 (KF1) was clean, without crumbs and ice-build up. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing food borne illness (food poisoning- with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) which could lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its infection control policies and procedures by failing to ensure:Staff donned (putting on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments such as a gown, gloves and mask) prior to entering Resident 16's room and staff performed proper hand hygiene by washing their hands with soap and water after leaving Resident 16's room who was under contact isolation (a transmission based precautions to stop germs from spreading through direct touch with a patient or indirect touch with contaminated objects in their environment) for Clostridium Difficile (C. diff; a highly contagious bacterial infection that causes an infection of the colon [the longest part of the long intestine]) infection. [...]

Inspectors wroteBased on observation and interview, the facility failed to close the privacy curtain (fabric barrier suspended from ceiling tracks to divide shared rooms, providing patients with immediate visual privacy, dignity, and a sense of security during examinations or treatment) to provide privacy for one (1) of twenty-three sampled residents (Resident 9), who was only wearing a diaper when the resident was returning to her bed from the bathroom. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one ( 1) of five (5) sampled residents (Resident 38) reviewed for unnecessary medication have a specific indication for the use of valproic acid (a prescription medication used primarily to prevent and treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and a mood stabilizer) as indicated on the facility's policy. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to monitor new onset of penile swelling as indicated on the care plan for one (1) out of 1 sampled resident (Resident 49) reviewed for edema. This failure resulted in the nursing staff not monitoring Resident 49's penile swelling daily for worsening or improvement and had the potential to negatively affect Resident 49's physical comfort and psychosocial (the interaction between a person's psychological [mental/emotional] state and their social environment [relationships, culture and surroundings] as it affects their health) well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to provide assistant devices to prevent accident for one (1) of three (3) sample residents (Resident 48) reviewed for fall by failing to provide floor mat (a protective, cushioned device placed on the floor beside a bed or in high-risk areas to reduce the severity of injuries-such as fractures or bruises-if a resident falls or rolls out of bed) after the resident has a fall in the facility. This failure placed Resident 48 at risk for another fall that may result to serious injury and hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma [trauma (results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being)]) by failing to identify trauma triggers (a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening) and develop and implement a treatment plan to address a diagnosis of post-traumatic stress disorder (PTSD- a mental health disorder that develops in some people who have experienced a shocking, scary, [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered and supervised as ordered when Licensed Vocational Nurse 3 (LVN 3) left medications on the bedside table for one (1) of 23 sampled residents (Resident 2). This failure had the potential to result in diversion (medications being misused, stolen, or not given to the right person as prescribed) or accidental ingestion of the medications by other residents that could lead to adverse outcomes and compromise the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Medication Regimen Review (MRR, review is a thorough, systematic evaluation of a patient's entire medication list) for one (1) of 23 sampled residents (Resident 38) by failing to reflect the correct diagnosis for the resident's use of valproic acid (a prescription medication used primarily to prevent and treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and a mood stabilizer) on the December 2025 and January 2026 MRR reports, which were in the resident's medical records. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the pancake style call light (soft touch call light - a specialized patient-assistance button designed for individuals with limited mobility, poor dexterity, or weak grip strength and only requires minimal, gentle pressure to activate) for one (1) of three (3) sampled residents (Resident 44) reviewed for environment was functioning properly. This failure had the potential to put Resident 44 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's staffing information was posted and placed in a visible and prominent area on 2/17/2026, 2/18/2026, and 2/19/2026 in accordance with the facility's policies and procedures (P&P). This deficient practice had the potential for the residents, staff, and visitors not to be informed of the actual number of nurses providing direct care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for one of three sampled residents (Resident 1), who was admitted with a peripherally inserted central catheter (PICC line - a long flexible catheter inserted through a vein in the upper arm). This deficient practice resulted in Resident 1 not receiving appropriate care, monitoring and assessment specific to her PICC line.

Inspectors wroteBased on interview and record review, the facility failed to ensure the peripherally inserted central catheter (PICC line- a long flexible catheter that is inserted through a vein in the upper arm) care and dressing was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1). Resident 1's PICC line was not changed every seven days as indicated in the facility's policy. This deficient practice had the potential to result in Resident 1 developing an infection on the PICC line insertion site.

Inspectors wroteS483.25(d) Accidents. The facility must ensure that - S483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) who was assessed as high risk for falls by failing to develop a comprehensive resident-centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) after Resident 1's fall on 8/10/2025. This deficient practice resulted in Resident 1's repeated fall on 8/12/2025 at 6:19 PM.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 3) who was assessed at risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities) was free from falls and injury in accordance with the resident's care plan for At risk for fall and Occupational Therapist (OT; a healthcare provider who helps you improve your ability to perform daily tasks like getting dressed or using a computer) Evaluation & Plan of Treatment (OTEPT) to provide maximal assistance (helper does more than half the effort) to the resident when showering/bathing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 222 and 11) were treated with respect and dignity in accordance with the facility policy by failing to ensure: 1. Resident 222 had a dignity bag (urine drainage bag holder to prevent public view) over the resident's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine). 2. Resident 11 did not have any food crumbs (small pieces of food that have broken off from a larger piece) on the resident's shirt on 12/16/2024. These deficient practices have the potential to negatively affect Residents 222 and 11's self-worth, self-esteem, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two residents (Resident 70 and Resident 71) reviewed for closed records had a discharge care plan. This failure had the potential to result in Resident 70 and Resident 71 increasing their risk of preventable readmissions due to not focusing on their discharge plan and goals, not actively preparing and effectively transitioning to post discharge care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 122 and Resident 22) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) treatment received communication records from the hemodialysis center when the residents returned to the facility. This failure had the potential to result in Resident 122 and Resident 22's health status not being communicated in a timely manner and not receiving appropriate post dialysis care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dry food items that had been removed from their original packaging were labeled with use by date, and refrigerated foods that had expired were discarded. This deficient practice resulted in exposing residents to expired food items, affecting the quality, taste, and texture of food, and potentially harming residents if they consumed expired food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was disposed properly for one of two dumpsters as indicated on the facility policy. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. Findings, During a concurrent observation and interview on 12/17/2024 at 1:19 PM with Infection Prevention Nurse (IPN), there were two dumpsters in a corner outside the facility by the facility parking lot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for two of 14 sampled residents (Residents 222 and 126) by failing to ensure the resident's call light (device used by residents to call staff) was within the resident's reach. This deficient practice had the potential for delayed provision of care to Residents 222 and 126, which could negatively affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 54), had the head of bed (HOB) elevated at minimum 30 degrees during tube feeding infusion in accordance with the facility policy. This deficient practice had the potential for Resident 54 aspirating (feeding could enter the windpipe and lungs) and result in complications such as aspiration pneumonia (an inflammation of the lungs and bronchial tubes that occurs after foreign matter was inhaled), hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 34), received Apixaban (medication to prevent blood clots) as indicated on the physician's order. This deficient practice had the potential to cause Resident 34 serious problems such as heart attack (a condition when blood flow to the heart muscle is suddenly blocked), deep vein thrombosis (DVT- a condition where a blood clot forms in a deep vein, usually in the legs, leading to serious complications), pulmonary embolism (a condition where a blood clot travels to and blocks an artery in the lungs), and stroke.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician addressed the medication regimen review (MRR/Drug Regimen Review - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) on 6/10/2024 to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (a medication used to treat psychosis) or document a clinical rationale as to why an attempt would be contraindicated for one of five sampled residents (Resident 52). [...]

Inspectors wroteBased on interview and record review, the facility failed to perform a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (a medication used to treat psychosis) or document a clinical rationale as to why an attempt would be contraindicated for one of five sampled residents (Resident 52.) The deficient practice increased the risk for Resident 52 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Seroquel therapy possibly leading to impairment or decline in the resident's mental, physical, and /or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and /or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure for two of 14 sampled residents (Residents 126 and 273) in accordance with the facility policy by failing to ensure: 1. Resident 126's used urinal with urine was not placed next to the uncovered cup of water and a cup of oatmeal on the resident's bedside table. 2. Resident 273's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not touching the floor. This deficient practice placed the Resident 126 at risk for potential infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their policy and procedure for norovirus (also often called food poisoning. It is the most common cause of diarrhea [watery stool] and vomiting [throwing up]) prevention and control for three of three sampled residents (Resident 1, 2 and 3) when facility did not cohort (a group of people with a shared characteristic) their staff assignment after they received a positive norovirus result for Resident 1 on 10/27/2024. This deficient practice placed all the other residents in the facility, facility staff and visitors at risk for contacting (exposure to contagious disease) norovirus.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) was not left unattended by facility staff while the resident is sitting on the bedside commode (a portable toilet) for long period of time. This deficient practice had a potential to result in skin breakdown and accidents that can lead to injury.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure for one of three (3) sampled residents (Resident 1) by failing to thoroughly investigate an allegation of sexual abuse (non-consensual sexual contact of any type with a resident. This deficient practice had the potential to place Resident 1 at risk for elder abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare settings) were followed in accordance with the facility ' s policy and procedure by failing to ensure the Certified Nursing Assistant 3 (CNA 3) wore an isolation gown while passing water pitcher inside a residents room with a resident (Resident 2) who was positive for Coronavirus-19 (Covid-19, an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions). This deficient practice had a potential to spread infection to all residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to administer medication in a safe and timely manner for two of two sampled residents (Resident 1 and 2) by ensuring: 1a. Resident 1 did not receive Tobramycin-Dexamethasone ophthalmic suspension (used to treat bacterial eye infections) 30 days after the open date as indicated in their policy. 1b. Resident 1 received Timolol Maleate (a medication used to treat glaucoma [eye disease that can cause vision loss and blindness by damaging a nerve in the back of the eye]) in accordance with the physician ' s order. 2. To administer Tylenol (a medication used to treat pain) according to pain parameters as ordered by the physician for Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection prevention procedure during medication administration for one of two sampled residents (Resident 1) by failing to ensure Licensed Vocation Nurse (LVN) 1 washed hands before administering Resident 1's oral medication, washed hands before wearing gloves and administering ophthalmic (pertaining to eye) medications as indicated in the facility policy. This failure had the potential to transmit infectious microorganisms and increase the risk of infection for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was answered for one (1) of four 4 sampled residents (Resident 1). On 5/7/24, Resident 1's call light was on, and it was not answered by Licensed Vocational Nurse (LVN) 1 who was standing across the resident's room, Certified Nurse Assistant (CNA) 2 and Registered Nurse (RN) 1 who passed by the room. This had the potential to result in a delay in care for Resident 1 not to receive the necessary care and services which can lead to illness or serious injury.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the safety and prevent fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) of two (2) of three (3) high fall risk sampled residents (Resident 2 and 3) by: 1. The facility failed to update care plan interventions and to reassess Resident 2's fall risk assessment after the resident's fall on 4/25/2024. 2. The facility failed to update Resident 3's care plan after resident had a fall on 4/9/2024. This deficient practice resulted to Resident 2 had another fall on 5/4/2024 and was sent to General Acute Care Hospital (GACH 1) and placed Resident 3 at risk for another fall incident.

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with facility's policy and procedures (P&P) titled, Psychotropic Medication (drugs that affect the person's mental state) Use, and Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) - Clinical Protocol, to ensure three of five sampled residents (Residents 10, 13 and 291) for unnecessary medication care area. Residents prescribed with psychotropic medications included clear, clinical indications for use or continued use to treat a specific condition. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide services and treatment to prevent urinary tract infection (UTI, clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract, including the urethra, bladder, ureters, and/or kidney) for two of four sampled residents (Resident 290 and 13) who have indwelling catheter (tube that drains urine from the bladder into a bag) by failing to: 1. Monitor and document signs and symptoms of UTI for Resident 290 on 1/30/2024. 2. Change Resident 13's indwelling catheter on 1/23/2024 as ordered by the physician. Theses deficient practices resulted in Resident 290 developing cloudy urine, worsening gross hematuria (blood in urine that can be seen with naked eye) and possible UTI. In addition, it may result to Resident 13 developing UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for two (2) of 2 sampled residents (Resident 289 and 243) for oxygen care area in accordance with the facility's policy and procedure when: 1. Resident 289 did not receive three (3) liters of oxygen continuously per physician's order. 2. Resident 243's nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was not properly placed on the resident's nostrils (two openings in the nose through which air moves when you breathe). These deficient practices had the potential to cause complications associated with oxygen therapy to Residents 289 and 243.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered in accordance with physician orders for two of six residents reviewed during medication administration pass. The facility failed to ensure: 1a. Resident 19's Metformin (a medication that treats type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) was not administered over two hours after the scheduled administration time of 7:30 AM, with instructions to administer daily with breakfast. 1b. Resident 19's blood pressure (BP) was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's combination BP medication, Lisinopril 20 milligram (MG, unit of measure of weight) with Hydrochlorothiazide (HCTZ) 12.5 MG 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Residents 10, 13, 291), for unnecessary medication care area, were free from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to: 1. Identify specific, measurable target behaviors related to the use of Seroquel (antipsychotic [medications used to treat mental illness]) for Resident 10 2. Identify specific, measurable target behaviors related to the use of Abilify (antipsychotic) and Seroquel for Resident 13. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage of controlled refrigerated medication (a prescription medicine that is subject to strict legal controls) and disposal of expired supplies for one of one medication storage rooms when: 1. A bottle of liquid lorazepam (medication used to treat anxiety) was not stored inside a locked box inside the refrigerator. 2. One (1) unopened foley catheter insertion tray (a soft, thin tube used to pass urine from the body) with expiration date of [DATE] was stored in medication room [ROOM NUMBER] (MR 1). 3, 15 unopened needles (a small tube used for injecting or withdrawing liquids) with expiration date of [DATE] was stored in MR 1. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with their policy and procedure by: 1. Facility failed to label food in the kitchen with item name, date opened and expiration date, and failed to discard expired food. 2. Facility failed to ensure kitchen equipment were clean and in good condition. 3. Failed to ensure there was no blanket and personal belongings stored in the kitchen storage. 4. Failed to ensure Dietary Staff performs hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) in between tasks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean the dryer lint trap for three (3) of 3 dryers located in the laundry room as indicated in the policy. This deficient practice had the potential to cause fire in the facility.

Inspectors wroteBased on interview and record review, the facility failed to promote dignity and respect for one of one resident (Resident 293) for dignity care area as indicated on the facility's policy when staff changed the resident's brief when the resident stated she was dry and did not need to be changed. This deficient practice had the potential to result in Resident 293's feelings of decreased self-esteem, self-worth, and experiencing distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff) was within reach for one of two residents (Resident 292) for the environment care area. The call light was observed hanging on the back of the resident's bed, out of reach (more than the arm's length) of Resident 292. This failure had the potential to result in a delay in or in inability for Resident 292 to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to notify one (1) of two (2) sampled residents (Resident 37) upon admission and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare (a federal health insurance for anyone age [AGE] and older/Medicaid (a joint federal and state program that gives health coverage to some people with limited income and resources) or by the facility's per diem (a payment rate determined for each day of the residents stay) rate, in accordance with the facility policy. This deficient practice resulted in payment of billed charges to Resident 37 which amounted to $21,420 prior to being discharged from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan within 48 hours of resident's admission for use of indwelling catheter (tube that drains urine from the bladder into a bag) for one of one sampled resident (Resident 13). This failure had the potential to result in Resident 13 not being provided with an effective and resident centered care which could result in urinary tract (urinary system) infection (UTI, condition in which bacteria invade and grow in any part the urinary system which includes the kidneys, bladder ureters [tube that carries urine from the kidney to the urinary bladder], and urethra [canal from the bladder]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive resident- centered care plan for eight (8) of 19 sampled residents (Residents 10, 13, 291, 289, 290, 15, 243, and 4), as indicated on the facility policy. 1. Resident 10 did not have a care plan to include non-pharmacological interventions (approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being) to address psychosis (a mental disorder characterized by a disconnection from reality). 2. Resident 13 did not have a care plan for the use of Abilify (medication used to treat mental illness) and use of indwelling catheter (tube that drains urine from the bladder into a bag). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one of 19 sampled Residents (Resident 28) when Resident 28/ Responsible Party's (RP) request to have the resident's suprapubic catheter (medical device that drains urine from bladder) dressing change after breakfast to provide more time for resident activities was not reflected on the care plan. This deficient practice had the potential for inconsistency of care being rendered for Resident 28, which could affect resident's well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for three (3) of seven (7) sampled residents (Residents 289, 27, and 4) for pressure injury care area, in accordance with the facility's policy and procedure by failing to ensure: 1. The low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct setting for Resident 289. The facility also failed to ensure Resident 289's pressure ulcer was assessed with measurements and documented on 1/27/2024. 2. The LAL was on the correct setting for Resident 27. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label an intravenous (IV-administered into a vein) medication with the resident's name, medication name, dosage, route, and time administered and an IV tubing (plastic tubing that connects the set-up to a bag of fluid to the IV) was not labeled with date initiated, time, and initials (licensed nurse who started the IV) for one of two sampled resident (Resident 289) for antibiotic care area. This deficient practice had the potential for Resident 289 to receive an incorrect IV medication as ordered by the physician and infection control risks from using an unlabeled IV tubing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 15) for pain care area, receive the treatment and care to address the resident's pain during rehabilitation exercise (aim to return full function following injury through re-building muscle strength, endurance, power and improving overall flexibility and mobility), in accordance with the facility's policy and procedure. This deficient practice had the potential to result in a delay of necessary care and treatment and unmanaged pain that could negatively affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call system (the means of the initial communication between staff and residents) was functional on two out of two (2) sampled residents (Resident 10 and 292). This deficient practice had a potential in a delay in meeting the residents' needs for assistance and can lead to frustration, falls and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reflect the correct number of staff posted based on the staffing assignment in accordance with the facility's policy. This deficient practice had the potential to inaccurately reflect the actual nurses providing direct care to the residents.