The Earlwood

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from sexual abuse for one of three sampled residents (Resident 1) after she reported an allegation involving Certified Nursing Assistant 1 (CNA 1) to CNA 2 on 5/28/2026. The facility failed to:1. Ensure CNA 1 was removed from providing care to Resident 1, after Resident 1 verbalized she does not want CNA 1 to take care of her on 5/28/2026 to CNA 2. These failures resulted in Resident 1 experiencing emotional distress and feeling unsafe in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report allegation of sexual abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH). The facility failed to:1. Implement its policy and procedures (P&P) titled, Abuse Investigation and Reporting dated 2/2017 which indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. This deficient practice resulted in a delay in reporting to CDPH and CDPH's investigation, and a potential risk for continued abuse, or mistreatment of Resident 1 and other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an alleged sexual abuse allegation for one of three sampled residents (Resident 1). The facility failed to:1. Initiate or complete an investigation after learning that Certified Nursing Assistant (CNA) 1 allegedly made a sexually inappropriate comment to Resident 1 while providing perineal care cleaning of the genital area and anal areas). This deficient practice had the potential to place Resident 1 and other residents at risk for unaddressed abuse, psychological harm, and fear, and it violated Resident 1's right to be free from abuse.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 11), was provided needed care and services when the resident had a change of condition ([COC] a sudden, clinically important deviation from a person's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) on 11/21/25. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of seven sampled residents (Resident 88), who was at risk for falls, had fall precautions in place to prevent the resident from falling on 10/13/2025 at 9 p.m., and 10/14/25 at approximately 1 a.m. (approximately 4 hours apart). The facility failed to:1. Update Resident 88's care plan titled Unwitnessed Fall to include interventions such as a bed alarm (fall prevention device that alerts caregivers when a patient attempts to get out of bed), landing pads (foam pads placed on the floor alongside a bed to cushion the impact of a person falling), and maintaining the resident's bed in the lowest position after Resident 88's first fall on 10/13/2025 at 9:00 p.m. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its policy on food handling and storage by not discarding expired crackers used for food preparation, which were 60 days past their expiration date. These deficient practices had the potential to cause foodborne illness (an illness resulting from consuming food contaminated with harmful microorganisms) among residents who rely on facility-prepared meals for their daily nutrition and well-being. During a concurrent observation and interview on 1/5/26 at 11:44 a.m. with Dietary Aid (DA 1) and Dietary Supervisor (DS) in the kitchen dry storage room, an open container of ground cracker crumbs was observed with an opened date of 10/11/2025, and a 'use by' date of 11/12/2025. The crackers remained available for use in food preparation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper infection prevention and control practices for six out of six sampled residents ( Resident 11,2,15, 1, 82 and 45) The facility failed to: 1. Ensure Resident 11's foley catheter (a soft flexible tube used to drain urine directly from the bladder) bag was not placed on the floor. 2. Failed to ensure Resident 2's water bag hydration was labeled with date and time when hung. 3. Ensure Resident 15's nasal canula (medical device use to give extra oxygen) and humidifier ( a household device that add extra moisture to prevent the air from dryness) were labeled with the date and time. 4. Disinfect Resident 1's and Resident 82's medication tray prior to using it to pass medications. 5. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure call lights were answered in a timely manner for two of two sampled residents (Resident 28 and Resident 61). This failure had the potential to delay care and prevent residents from receiving assistance with activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to inform and provide evidence that a resident's representative was informed of the right to formulate an Advance Directive(a legal document indicating resident preference on end-of-life treatment decisions) for one of six sampled residents (Resident 24) who was diagnosed with dementia (a progressive state of decline in mental abilities) and lacked the capacity to understand and make decisions. This failure had the potential to cause conflict with the resident or responsible party regarding alternatives in the provision of health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 33 and Resident 44) discharged to a general acute care hospital (GACH) had a necessary and appropriate transfer and failed to complete assessment or document attempts to meet resident needs. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (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) for one of four sampled residents (Resident 13) or resident 's representative ([RP] resident's representative-individual acting on behalf of the resident) at the time of transfer to a General Acute Care Hospital(GACH). This failure had the potential to result in an inappropriate discharge by not informing Resident 13 and / or their RP of the right to receive a bed hold and to return to the facility after hospitalization.

Inspectors wroteDuring an interview and record review the facility failed to ensure one of two sampled resident (Resident 7) had a Level II preadmission screening and resident review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services). This failure had the potential to place Resident 7 at risk of inappropriate placement, not receiving necessary care, and unidentified specialized services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a person-centered care plan with measurable interventions was created and implemented for one of two sampled residents (Resident 11), when on 11/20/2025, the resident started vomiting and complained of generalized pain of 10/10. This deficient practice had the potential to negatively impact the delivery of necessary care and services for Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to revise, review and update the care plan for one of two sampled Residents (Resident 13) addressing Resident 13's risk for pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential to result in a recurrence of Resident 13's pressure injury in the coccyx (tailbone).

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 11) who complained of stomach and arm pain rated at 10/10, on a pain scale rating of 0-10 (where 0 to 3= mild pain, 4 to 7 =moderate pain, 8 to 10 = severe pain, and 10 = the worse pain possible) was assessed, medicated and monitored. The facility failed to: 1. Ensure Registered Nurse Supervisor (RNS) 3 assessed and monitored Resident 11's pain after Resident 11 complained of severe pain of 10/10 on 11/21/25. 2. Ensure RNS 3 administered pain medication to Resident 11 when on 11/21/25 at 2:59 p.m., Resident 11 complained of severe pain rated at 10/10, as documented in the Nurses Progress notes on 11/21/25 at 2:59 p.m.3. Develop an individualized care plan for Resident 11 with interventions to monitor, prevent or manage Resident 11's pain. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure timely completion of STAT (immediately) laboratory tests for one of two sampled residents (Resident 11) as ordered by the Nurse Practitioner on 11/22/25 at 7:13 p.m., without waiting until 11/23/25 at 8:00 a.m., (approximately 13 hours) after the orders were received. This failure had the potential to negatively impact Resident 11's health by delaying critical diagnostic information necessary for timely treatment decisions, increasing the risk of the resident's condition worsening, leading to complications, and compromising the overall quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Residents 33 and 79) were provided with food that was appetizing, pleasing, and palatable. This failure had the potential to result in missed meals and subsequent weight loss.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of two sampled residents (Resident 77) was assessed for meal preferences, including likes and dislikes. This failure had the potential to result in Resident 77 refusing meals and experiencing weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 42) received a speech language pathology evaluation (assessment performed by a speech therapist [evaluates and treats speech language and swallowing difficulties] to determine whether a person has communication disorders, swallowing or feeding disorders) as ordered by a physician on 12/10/2025. This failure had the potential to result in delay of care and put the Resident 42 at risk for aspiration pneumonia (lung infection from inhaling foreign substances like food, liquid or vomit often due to swallowing problems causing inflammation and potential bacterial infection in the lungs) leading to hospitalization and or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Quality Assessment /Quality Assurance and Performance Improvement (QA/QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) was utilized effectively for identifying resident care concern such as falls, quality of care and ineffective pain management. These failures had the potential to affect residents' quality of care, safety and life.

Inspectors wroteBased on observation and record review, the facility failed to ensure four out of 40 resident rooms measured at least 80 square feet ([sq. ft.]- unit of area equal to a square foot long on each side) per resident in multiple resident rooms (1, 2, 4 and 23). This failure had the potential to result in inadequate space to provide safe nursing care and privacy for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure indoor temperatures were maintained between 71 to 81 degrees Fahrenheit (a temperature scale) for five of five sampled residents (Residents 1, 2, 3, 4, and 5). On 12/31/2025, temperatures were recorded between 66 to 68 degrees Fahrenheit in the activity room (state and federally mandated common area specifically designed, equipped, and furnished for residents to participate in a planned program of social, recreational, and educational activities) in the hallway serving resident rooms 1-10 and in resident rooms. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was seen by an oral surgeon (Dental specialist that performs surgery on mouth jaw and face). This deficient practice had the potential for Resident 1 to have gum disease, tooth loss and an overall poor quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were honored for one of three sampled residents, (Resident1). This deficient practice violated Resident 1's rights and had the potential for malnutrition and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to obtain resident's written consent and document in his chart the basis of why the move was required prior to a room change for one of four randomly selected residents (Resident 3). This deficient practice resulted in the lack of opportunity for Resident 3 to see the new location, meet the new roommate and ask questions about the move prior to the room changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4), who had orders in place for test and/or consultations, had those orders implemented. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, 4.a. During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physicians for four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) when their appointments for test and/or consultations were missed or not scheduled. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, and 4. a. During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a consultation outside of the facility with a cardiologist (a doctor who specializes in the heart and blood vessels) on 3/24/2025, returned to the facility with progress notes and instructions for care that were available for review in Resident 1's medical record. This deficient practice resulted in a delay in scheduling Resident 1's micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx ([voice box]) for vocal cord lesion removal and had the potential for complications occurring based on that delay in surgery. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of two sample residents (Resident 1) by failing to: 1. Ensure proper Personal Protective Equipment (PPE: equipment worn (gown, gloves, goggles) to help create a barrier between a healthcare worker and germs) was worn for Resident 1 that was on Enhanced Barrier Precaution (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs).2. Ensure proper hand hygiene was performed during glove changes.3. Ensure Resident 1's indwelling catheter (or 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.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of the four sampled residents (Resident 1 and Resident 2) change of condition (COC: when there is an alteration in an individual's physical or psychosocial wellbeing) were implemented by: 1. Failing to monitor Resident 1 who was diagnosed with Scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) after treatment was administered. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of four sampled residents (Resident 2) received care to prevent pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to the sacrococcyx area. This deficient practice resulted in Resident 2 developing a stage II pressure injury on the sacrococcyx (fused bone structure that consists of the sacrum [triangular bone at the base of the spine] and coccyx [tail bone]) area and had the potential for risk of infection and pain. [...]

Inspectors wroteBased on interview and record review the facility failed to notify one of three sampled resident's (Resident 2) physician and the facility's registered dietician (RD), when Resident 1, had a poor food intake, and refused to be weighed. These deficient practices resulted a delay in Resident 2's evaluation and care and had the potential for Resident 2 to become malnourished and lose weight.

Inspectors wroteBased on interview and record review the facility failed to ensure the weights and food consumption for one of three sampled residents (Resident 2) was obtained and/or assessed. These deficient practices resulted in Resident 2's weights and food consumption being unknown and a delay in evaluation and care. These deficient practices placed Resident 2 at risk for malnutrition and weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure their QA/QAPI (Quality Assurance/Quality Assurance and Performance Improvement, a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee monitored interventions put in place related to delays in receiving resident care. This deficient practices resulted in the inability of the facility to determine if interventions put in place to improve resident care in a timely manner were affective and placed residents at risk for continued delay in care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of elopement (act of leaving a facility unsupervised and without prior authorization) and wandering (moving from place to place) behaviors did not elope from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 6/5/2025 at approximately 5:32 p.m., unbeknownst to staff. Resident 1 was returned to the facility on the same day after being found by a Good Samaritan at approximately 5:55 p.m. This deficient practice place Resident 1 at risk for harm as a result of in climate weather, motor vehicle accidents, fall, violence at the hands of others and death. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor two of two sampled resident (Resident 11 and Resident 12) after a change of condition occurred. This failure had the potential to result in a potential delay of care to Resident 11 and Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a physician's order before administering oxygen to one of three sampled residents (Resident 13). This failure had the potential to result in a potential for hyperoxygenation (too much oxygen) Resident 13.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff were competent in administering oxygen. This failure had the potential to result in a potential for hyperoxygenation (too much oxygen) Resident 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 10 sampled residents, Resident 4, Resident 5, Resident 6, and Resident 7) were provided with a safe, clean, comfortable, and homelike environment. The facility failed to: 1. Provide a room for Resident 4, Resident 6, and Resident 7) with functional sliding glass doors that able to be locked from the inside. 2. Provide a safe environment for the staff and residents by locking the entrance doors (front door) to the facility during the night. 3. Maintain Resident 4 and Resident 5 rooms free from cockroaches. These deficient practices had the potential to affect the residents ' dignity, the residents ' mood, and the residents ' rights to have a homelike and safe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 10 sampled residents, Resident 4, Resident 5, Resident 6, and Resident 7) were provided with a safe, clean, comfortable, and homelike environment. The facility failed to: 1. Provide a room for Resident 4, Resident 6, and Resident 7) with functional sliding glass doors that able to be locked from the inside. 2. Provide a safe environment for the staff and residents by locking the entrance doors (front door) to the facility during the night. 3. Maintain Resident 4 and Resident 5 rooms free from cockroaches. These deficient practices had the potential to affect the residents ' dignity, the residents ' mood, and the residents ' rights to have a homelike and safe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) were free from unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) as evidenced by: 1. Resident 1 and 2 ' s bed was against the wall. This deficient practice had the potential to place Residents 1 and 2 at risk for injury and the potential for entrapment (when an individual is trapped or unable to get out of a small, enclosed area).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives, timeframes, and interventions for two of 10 sampled residents Resident 1and 2) by failing to: 1. Review and revise Resident 2 ' s care plan after each incident of fall. 2. Develop a care plan for Residents 1 and 2 ' s bed against the wall. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 1 and 2.

Inspectors wroteBased on observation and interview, the facility failed to maintain a consistent and effective pest control program as evidenced by: 1. Multiple live cockroaches were found on the wall of Resident 4 and Resident 5 ' s room (room [ROOM NUMBER]). This deficient practice had the potential to affect the quality of life of Residents 4 & 5 and the potential of roaches spreading to other rooms in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when a resident experienced a change of condition([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) for four of five sampled residents (Resident 1, 2, 3 and 4). The facility failed to: 1. Ensure licensed nurses notified Resident 1, 2, 3 and 4 ' s physician when Resident 1, 2, 3 and 4 did not receive their 9:00 a.m. scheduled medications on 4/19/2025. 2. Ensure licensed nurses documented a COC when schedule medications were not administered to Resident ' s 1, 2, & 4 on 4/19/2025 at 9 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staffing on 4/19/2025 when one licensed nurse called off and one no call no show (an employee fails to report to work as scheduled and fails to notify their employer of their absence) to accommodate resident needs in administering medications timely. This deficient practice resulted in Resident 1, 2, 3 and 4 not receiving all scheduled medications on 4/19/2025 at 9 a.m.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of five sampled resident (Resident 1,2,3, and 4) medications were administered within one hour of their scheduled administration time in accordance with the facility ' s policy and procedures titled Administering Medications, (undated). These deficient practices placed Residents 1, 2, 3, and 4, at risk to experience medication adverse reactions, and complications including a high blood pressure leading to stroke (damage to the brain from interruption of its blood supply), venous thromboembolism (blood clots in the veins), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and hospitalization.

Inspectors wroteBased on observation and interview, the facility failed to implement and maintain infection control practices when Certified Nurse Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 2 failed to perform hand hygiene between resident care and prior to entering and exiting resident rooms. These failures had potential of cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed residents and staff at risk for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory tests per medical doctor (MD) order prior to resident scheduled appointment for one of three sampled residents (Resident 2). This deficient practice resulted in Resident 2 ' s medical doctor appointment to be canceled and had the potential delay in necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to have an Infection Preventionist (IP) on staff with completed specialized training in Infection Control and Prevention. This deficient practice had the potential for failure to monitor and implement Infection Control and Prevention in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care by failing to: 1. Document on the Medication Administration Record (MAR) meclizine (medication used to help with dizziness) medication was given as ordered by the physician. 2. Initiate a plan of care and change of condition when a Resident 1 has new onset of cough . These deficient practices had the potential to cause Resident 1 side effects of the medication not being monitored and had to potential to miss treatment and care for new onset of cough.

Inspectors wroteBased on observation interview and record review the facility failed to: a. Ensure an open container of apple sauce had an open date and a use by date on the container. b. Ensure an open container of beef base had an open date and a use by date on the container. c. Ensure frozen chicken tenders that were stored in a Ziploc bag had an open date and a use by date on the bag. d. Ensure that pork was defrosted safely, when pork was left in a bowl of standing water while defrosting in the sink. These failures had the potential to expose residents to a food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the individual needs and preferences of two of 21 sampled residents (Resident 37 and Resident 179) by failing to: a. Address Resident 37's concern regarding insufficient space of his room which prevented him to move around comfortably and access his closet and wheelchair easily due to limited space. b. Address Resident 179's concern about the noise coming from resident's roommate which affected his sleep. These failures had the potential to affect Resident 37's and Resident 179's health, psychosocial wellbeing and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 45 sampled residents (Resident 6, 17, and 34), were provided privacy curtains to completely cover the residents during care. This failure prevented Resident 6, 17, and 34 from having complete privacy during care and had the potential to affect their dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plans for two of four sampled residents (Resident 6 and 20) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns by failing to: a. Revise Resident 6's care plans and conduct an Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) conference with the resident's representative after discharge from hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 1/13/2024. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Administer medications within one hour of their prescribed time as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019, affecting two of five residents observed during medication administration (Resident 1 and 228). 2. Accurately account for the administration of a combination medication, hydrocodone (a controlled substance [a medication with a high potential for abuse used to treat pain] and acetaminophen (APAP - a medication used to treat fever and pain) on Controlled Drug Record (CDR- a log signed by the nurse with the date and time each time a controlled substance is given to a resident) affecting one resident (Resident 332) in one out of two inspected medication carts (Medication Cart 3). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sampled resident (Resident 25 and 29) was free from unnecessary medication. The facility failed to: a. Ensure Resident 25 continued use of antibiotic was reviewed when Resident 25 did not meet LOEB's criteria (set of guidelines used by healthcare providers in for long term care facilities to determine when a resident likely has a significant infection and needs antibiotics based on symptoms) indicating antibiotic use. This deficient practice of failing to ensure a continued need for antibiotics (medications that fight bacterial infections) increased the risk for Resident 25 to experienced antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) from unnecessary antibiotic use. b. Ensure Resident 29 Tramadol (pain medication) was given according to physician orders. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Insulin Lispro prefilled pens [a type of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) delivered via injection device] were stored and/or labeled in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled Medication Labeling and Storage, dated 02/2023 affecting two residents (Resident 4 and 62) in one of two inspected medication carts (Medication Cart 3). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of infection. The facility failed to: a. Ensure hand hygiene was performed at appropriate times during a gastrostomy tube ([GT]- a tube inserted through the wall of the abdomen directly into the stomach) site dressing change for Resident 6. b. Observe Contact Precautions ( are set of safety measures used when a resident has a disease that can be spread thru contact with the patient or patient's environment) before entering Resident 22's room who had a methicillin resistant staphylococcus aureus ( MRSA-type of bacterial infection that is resistant to many antibiotics) and Candida Auris(C. Auris- type of yeast or fungus that can cause serios infections and are difficult to treat because it is resistant to many antifungal medications). c. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain respect and dignity to one of three sampled residents (Resident 57) by standing over the resident while assisting them during a meal. This failure had the potential to result in decreased self-esteem and self-worth for Resident 57.

Inspectors wroteBased on interview and record review, the facility failed to ensure a change of condition (COC), was completed when Resident 30 developed a urinary tract infection ([UTI]- an infection in any part of the urinary system). This failure had the potential to result in the inability to determine the improvement or worsening of the infection leading to Resident 30 not receiving the appropriate care.

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 care) I for one of three sampled residents (Resident's 18). This failure had the potential to result in an inappropriate placement and delay of needed services for Resident's 18.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary services and care to two of four sampled residents (Resident 18 and Resident 45) by failing to: a. Ensure Resident 18 was provided the necessary medications for constipation (a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) when the resident had no bowel movement (movement of feces through the bowel and out the anus) for five days. b. Monitor occurrence of bowel movement for Resident 45 and provide necessary medications for constipation as ordered by the physician. These failures had the potential to put Resident 18 and Resident 45 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to bowel obstruction (partial or complete blockage of small or large intestines which is life threatening).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of five sampled residents (Resident 1 and 228) by failing to provide medications within one (1) hour of the prescribed time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019. This deficient practice of medication administration error rate of 25.93% exceeded the five (5) percent threshold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for two (Resident 1 and 228) of five sampled residents, by failing to administer: 1. Resident 1's Amlodipine (a medication used to treat high blood pressure), Eliquis (Generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain) and Hydralazine (a medication used to treat high blood pressure) within one (1) hour of the prescribed time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) Records for one of four sample residents (Resident 17) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) indicated Resident 17's refusal to wear the right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) on 11/12/2024. This failure resulted in the inaccurate provision of care recorded in Resident 17's clinical records.

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] for one of three residents (Resident 25). This failure had the potential to put Resident 25 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four out of 40 resident rooms measured at least 80 square feet ([sq. ft.]- unit of area equal to a square foot long on each side) per resident in multiple resident rooms. Rooms one and 23 house two residents per room and Rooms two and four housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who refused to be placed back to bed, did not sustain an injury, when a Certified Nursing Assistant (CNA 1) picked her up and placed her in bed against the resident wishes, for one of four sampled residents (Resident 2). The facility failed to: 1. Ensure CNA 1 honored Resident 1's decision not to go back to bed and did not force the resident against her wishes back to bed by holding her tightly, which resulted in Resident 1 becoming combative as she resisted CNA 1's attempt to place her back to bed. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed that addressed the behaviors of yelling, screaming and refusal of care for one of four sampled residents (Resident 2). This deficient practice resulted in Resident 2's care needs not being addressed and had the potential for non-continuity of care.

Inspectors wroteThe facility failed to ensure two of nine sampled residents (Resident 6 and 9) oxygen tubing (device that delivers oxygen [air essential to living things to survive] through a tube to the nose) were labeled and dated. This failure has the potential for the oxygen tubing to lose patency that could negatively affect and delay delivery of care and services to Resident 6 and Resident 9.

Inspectors wroteBased on interview and record review, the facility failed to maintain the roof in good repair for one of one sampled residents (Resident 1), when Resident 1 ' s room had leaking water. This deficient practice resulted in Resident 1 being exposed to an unsanitary environment and violated Resident 1 ' s right to be provided with a safe, clean, and comfortable homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services for one of four sampled residents (Resident 1) when: a. The facility failed to immediately transfer Resident 1 to GACH (General Acute Care Hospital) after Resident 1 had a change of mental function on 11/26/2023. Resident 1 had an order to transfer to GACH at 12:37 p.m. Resident 1 was transferred to GACH at 3:23 p.m. b. The facility failed to ensure Licensed vocational nurse 1 (LVN 1) and Registered Nurse Supervisor (RNS 1) assessed Resident 1's neurological status (a series of tests that assesses mental status, reflexes, movements and more) immediately after the change of condition and frequently until Resident 1 was transferred to GACH three hours after the change of condition. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare 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 60 out 66 total residents in the facility by not: a. ensuring facility staff changed gloves and washed their hands between tasks in the kitchen. b. ensuring facility staff with a beard used a beard cover while handling food in the kitchen. c. ensuring food stored in the resident refrigerator was stored for the correct time frame. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to address the following for three of seventeen sampled residents (Resident 40 and Resident 10), including: 1. failed to develop and implement a comprehensive and resident-centered care plan regarding Resident 40's communication needs, visual deficits, and visual deficits. 2. failed to ensure there was a care plan developed to monitor and address resident's behavior related to the use of a psychotropic, for one (1) of 31 sampled residents (Resident 10). These deficient practices have the potential to delay care or services provided for Resident 40 and Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a. revise one of 17 sampled residents' (Resident 19) care plan to reflect Resident 19's current Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) orders and treatment plan. b. implement the comprehensive care plan for one of one sampled resident (Residents 54) who sustained a fall on 10/9/2023. This deficient practice had the potential for Resident 19 to not receive the most current RNA treatment plan and staff may not know the correct services to provide the resident. This deficient practice had the potential to place Resident 54 at risk for recurrent falls.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one (1) hour of their prescribed time for Resident 3, one of 31 sampled residents. On 10/25/23, Resident 3 received 10 oral medications 2 hour after the prescribed time. Also, Resident 3 were scheduled to receive 71 doses intravenous (IV, to the vein) Zyvox (a potent antibiotic medication to treat severe systemic infection) administrations as of 10/26/2023; however, and 18 of those 71 doses were documented more than 1 hour late. (Also see F760) 2. Nurses documented in MAR after administering medications, and /or reason it was missed for 2 of 31 sampled residents (Residents 3 and 470). For Resident 3, there was no administration documentations for 12 doses of IV Zyvox. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure antipsychotic (medications that treat psychosis [a severe mental condition that affects thoughts and emotions and causes a break with reality]-related conditions and symptoms) and psychotropic (medications that affect a person's mental state) medication orders for three (3) of 31 sampled residents (Residents 26,10, and 12). For Resident 26, the antipsychotic medications did not have documented rationale for the use of Abilify (an antipsychotic) to treat a specific, diagnosed, and documented behavior. The facility also failed to ensure there was a monthly report of consolidated behavioral data available to the prescribersFor Resident 10, resident's psychotic medication order did not have an indication (a reason) of use or treat a specific and documented behavior. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one (1) hour of their prescribed time for Resident 3, one of 31 sampled residents. On 10/25/23, Resident 3 received 10 oral medications 2 hour after the prescribed time. Also, Resident 3 were scheduled to receive 71 doses intravenous (IV, to the vein) Zyvox (a potent antibiotic medication to treat severe systemic infection) administrations as of 10/26/2023; however, and 18 of those 71 doses were documented more than 1 hour late. (Also see F760) 2. Nurses documented in MAR after administering medications, and /or reason it was missed for 2 of 31 sampled residents (Residents 3 and 470). For Resident 3, there was no administration documentations for 12 doses of IV Zyvox. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records by failing to ensure the following: a. Resident 21's Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment provided on 10/25/23 was accurately documented by Restorative Nursing Aide 2 (RNA 2), the RNA who performed the RNA treatment session. b. Resident 47's Interdisciplinary Therapy Screens (facility's resident's functionality screening documentation) dated 6/23/23 was included in Resident 47's medical record. c. Resident 28's Interdisciplinary Therapy Screens dated 9/29/23 and 10/25/23 was included in Resident 28's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program for two of two sampled residents (Resident 3 and Resident 30) by failing to: 1. Ensure the Certified Nursing Assistant 8 (CNA 8) and two visitors followed Resident 3's transmission-based precautions (TBP- residents who are known or suspected to be infected or colonized with infectious agents) to prevent spread of infections. 2. Offer personal protective equipment(PPE- equipment worn to minimize exposure to hazards) and inform the visitor why Resident 30 is on enhanced barrier precaution. These deficient practices had the potential to result in the spread of diseases and infection to the facility residents, staff, and the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations to meet the resident's needs by failing to ensure the resident room was not cluttered and the grab bar (a safety device attached to the wall designed to enable a person to maintain balance) was not easily within reach for Resident 18 who used a wheelchair. This deficient practice had the potential for delay of care in case of emergencies and not meet the Resident 28's daily needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess and monitor one of one sampled resident (Resident 54) during the use of a concave mattress (a fall prevention mattress to minimize risks of falling out of the bed) to prevent the resident from sliding off the bed. This deficient practice had the potential for Resident 54 restricts freedom of movement or activity while in bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for one of 19 sampled resident's (Resident 21) Minimum Data Set assessment (MDS, a standardized assessment and care-screening tool). This deficient practice had the potential to cause inaccurate care planning and inadequate provision of rehabilitation therapy and restorative nursing services for Resident 21.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 16) had an accurate preadmission screening and annual resident review ([PASRR], is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) to determine the facility's ability to provide any special needs for the resident. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange for provision of vision services for three (3) of four (4) sampled residents (Resident 4, Resident 26 and Resident 28). This deficient practice resulted in Resident 4 not having vision evaluated to prevent further decline, Resident 26 not having vision evaluated for new glasses to allow Resident 26 to read the daily chronicles, and Resident 28 not having the annual vision evaluation to maintain and/or improve his vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician's orders for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) to put on a right elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and right resting hand splint included safe parameters (fixed time limits) for splint wearing time for one out of 17 sampled residents (Resident 19). This deficient practice had the potential for Resident 19 to develop pain and skin breakdown due to wearing splints for longer than Resident 19 could tolerate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient space for storage of non-therapy nursing items in order to provide adequate space for rehabilitative therapy services provided in the rehabilitation gym. This deficient practice had the potential to minimize the usable treatment space of the rehabilitation gym and create a cluttered, crowded environment for residents receiving therapy services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safe guard the personal clothing of two of two sampled residents(Resident 1 and 2). These deficient practices violated Residents 1 and 2's rights and caused Resident 1 to feel sad and Resident 2 to feel angry because their personal clothing were not available for use.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who had a history of elopement ( when a resident who is not capable of protecting or caring from themselves leaves the facility unsupervised) on 1/5/2022 and wandering (a person that roams around and becomes lost or confused about their location) had adequate supervision and monitoring (staff that are immediately at hand to redirect a resident from dangerous situations) for one of one sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was monitored for elopement and wandering behavior when the facility's front door was remodeled, and the wander guard sensor ( alarm to signal if a resident at risk for elopement tries to exit the facility) was disabled on 9/19/2023. 2. [...]