The Gardens of El Monte

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours, in accordance with the facility's policy and procedure (P&P), titled Abuse Reporting and Prevention, revised 04/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and document the investigation of an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P), titled Abuse Reporting and Prevention, revised 04/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to:1. Send Resident 1 for timely medical treatment after falling and hitting his head on the floor.2. Ensure three of five sampled residents (Resident 3, Resident 4, and Resident 5) received treatment and care in accordance with the physician's order for orthostatic blood pressure monitoring (involves measuring blood pressure (BP) while lying down, sitting, and standing to assess changes) by failing to ensure Resident 3, Resident 4, and Resident 5 were monitored for orthostatic hypotension (condition in which the blood pressure quickly drops upon standing up after sitting or lying down) with two blood pressure (BP) readings on 6/7/26, 6/14/26 and 6/21/26 and observed for adverse side effects. These deficient practices had the potential to result in adverse outcomes:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper storage of medications in one of two medication carts (Medication Cart 1). This deficient practice had the potential for medication dispensing errors for 25 residents who resided in the facility's Station 1 Unit. During an observation of Medication Cart 1 on 6/23/26 at 2:15 p.m., in Station 1 Unit, with Licensed Vocational Nurse 1 (LVN 1), the locked narcotics (a drug that is classified as a Schedule IV controlled substance and in moderate doses dulls the senses, relieves pain, and induces sleep) drawer with active medications was observed with 4 loose medications in the back of the narcotics drawer. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its Policy and Procedure (P&P) titled, Abuse Reporting and Prevention, for two of three sampled residents (Resident 6 and Resident 7) when the facility did not report two resident to resident abuse allegations (a claim that abuse has occurred) to the California Department of Public Health (the Department), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement, within two hours. This failure resulted in the delay of notification to the Department and had the potential for Resident 6 and Resident 7 to be subjected to abuse while at the facility. A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat two of two sampled residents (Residents 9 and 37) with respect, privacy and dignity in accordance with the facility's policy and procedure (P&P) titled Resident Right to Dignity and Privacy. These failures had the potential to cause psychosocial (mental and emotional well-being) decline and low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to document in the residents' medical record the transfer report of two of two sampled residents (Residents 6 and 8) to a General Acute Care Hospital (GACH). These deficient practices resulted in incomplete records for Residents 6 and 8 and had the potential to affect the continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the policy and procedure (P&P) on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) was implemented for one of one sampled resident (Resident 37) by failing to ensure Resident 37's AD Acknowledgment Form (ADAF) was updated to reflect whether the resident had an AD. This failure had the potential for the facility staff to provide medical treatment and services against the will of the residentFindings: During a review of Resident 37's admission Record (AR), the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by diseases or toxins in the body) and dementia (a progressive state of decline in mental abilities) with other behavioral disturbance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to encode the resident's bilateral bolster wedge cushions (used to offer support to various parts of the body) on the Minimum Data Set (MDS- a resident assessment and care screening tool) dated 2/26/2026 as a restraint for one of one sampled resident (Resident 3). This violation had the potential to negatively impact Resident 3's quality of care.

Inspectors wroteBased on interview and record review, the facility failed to revise the Care Plan (CP) for Fall for one of one sampled resident (Resident 1). This deficient practice resulted in a care plan that was not individualized, placing the resident at risk for preventable falls.

Inspectors wroteBased on interview and record review, the facility failed to monitor behavior for a high-risk elopement (a resident with an increased risk of leaving a supervised care facility) resident to prevent an elopement (patient leaves a healthcare facility without authorization or proper discharge) for one of one resident (Resident 16). This deficient practice resulted in Resident 16 eloping from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to complete and post the nurse staffing information hours at the start of each shift. On 4/7/26, the facility did not post the nurse staffing information for the current dates and did not indicate the total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice violated the residents' right and had the potential to inaccurately reflect the actual nurses providing direct care to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services when one pill was found lying on the hallway floor. This failure had the potential to result in a resident taking the pill and leading to adverse side effects (unwanted undesirable effects that are related to a drug).

Inspectors wroteBased on interview and record review, the facility failed to accurately date a resident's Care Plan (CP) for one of one sampled resident (Resident 16). This failure resulted in inaccurate documentation and had the potential to negatively impact the resident's quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of 23 resident rooms (Rooms 2, 8, 10, 11, 15, and 16) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This failure had the potential for these rooms to lack enough space for activities of daily living and hinder staff from providing care to these residents.

Inspectors wroteBased on interview and record review, the facility failed to administer Depakote (a medication used to help control mood symptoms and behavior issues) per the physician's order for one of three sampled residents (Resident 1). This violation had the potential to compromise Resident 1's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents receive written notice before the resident's room or roommate in the facility being changed for two of seven sampled residents (Resident 1 and Resident 6). These deficient practices violated Resident 1 and Resident 6's rights and had the potential to affect Resident 1 and Resident 6's psychosocial well-being.(cross reference F656)

Inspectors wroteBased on interview, and record review, the facility failed to ensure a safe and orderly transfer or discharge from the facility for three of ten sampled residents (Resident 1, Resident 3, and Resident 19) by failing to ensure:1. not discharge Resident 1 to another same level care Skilled Nursing Facility (SNF) 2 without physician's order, indicating the appropriate reason for discharge and providing Notice of Transfer/Discharge (NTD) to the resident to obtain a consent from the resident prior to discharge on [DATE].2. not discharge Resident 3 to another same level care SNF 3 without indicating the reason for discharge and providing NTD to the resident to obtain a consent prior to discharge 11/21/2025.3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure document the appropriate content on the Notice of Transfer/Discharge (NTD) form for three of ten sampled residents (Resident 1, Resident 3, and Resident 19) by failing to ensure:1. indicate the appropriate reason to transfer Resident 1 to another same level care Skilled Nursing Facility (SNF) 2 on 12/5/2025.2. indicate the appropriate reason to transfer Resident 3 to another same level care SNF 3 on 11/21/2025.3. indicate the location of an Independent Living Home (ILH) 1, where Resident 19 was transferred on 8/1/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the nurse staff developed and implemented the person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of seven sampled residents (Resident 1) to monitor Resident 1's psychosocial well-being and satisfaction after Resident 1 was being moved to a new room. This deficient practice had the potential to place Resident 1 at risk of not receiving the individualized care services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.(cross reference F559)

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff provided social services to assist one of three sampled residents (Resident 1) to get a legal personal identification (ID) card. This deficient practice violated Resident 1's right and had the potential to affect Resident 1's mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 5) was treated with respect and dignity by failing to ensure Activities Assistant (AA) 1 allowed Resident 5 to get up from the reclining wheelchair (wheelchair with backrest that moves backward so users can transition from an upright seated position to a horizontal position) on 12/1/2025 at 1:25 pm. This failure resulted in Resident 5 being confined (restricted) to Resident 5's reclining wheelchair and had the potential for Resident 5 to develop a decline in range of motion (ROM- how far and in what direction a joint or muscle can move), the ability to stand, quality of life, and lead to psychosocial (mental, emotional, social, and spiritual effects) harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free of unnecessary restraint. This failure had the potential for Resident 2 being unable to move around freely and placed Resident 2 at risk of injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a care plan for mental health services and increased socialization to prevent isolation for one of three sampled residents (Resident 2) who was being seen by the psychiatrist (a medical doctor who diagnoses and treats mental, emotional, and behavioral disorders). This failure resulted in Resident 2 feeling sad and isolated and had the potential for Resident 2 to receive inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to implement and revise the care plan for one of three sampled residents (Resident 1) who were assessed at high risk for falls in accordance with the facility's policy and procedure (P&P) titled, Falls by a Resident by failing to ensure: 1. Resident 1 was supervised and assisted while walking in the hallway on 9/6/25 in accordance with Resident 1's fall risk care plan. This failure resulted in Resident 1 falling on 9/6/25 and sustaining bruises, swelling, and an open wound on the forehead. 2. Resident 1's fall risk care plan was not revised with new interventions after Resident 1 fell on 9/6/25. This failure placed Resident 1 at risk for future falls and injury. Resident 1 fell on [DATE] and sustained bruises on the right side of the forehead, on the right eye, and on the right side and left side of the face.

Inspectors wroteb. During a review of Resident 42's AR, the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames the lung) and type 2 DM. During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42 had severely impaired cognition for daily decision making. The MDS indicated Resident 42 was dependent (helper does all of the effort) to staff for toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 42's AD Acknowledgement Form dated 12/6/2024, Resident 42's AD Acknowledgment Form was not filled out completely. During an interview with the Social Worker (SW), and concurrent record review of Resident 42's AD Acknowledgement Form on 3/15/2025 at 4:25 pm, the SW stated, the AD Acknowledgement Form was not filled out completely. [...]

Inspectors wroteBased on interview and record review, the facility licensed staff failed to perform a thorough assessment and to immediately notify the physician of a resident's sudden change of condition (COC) for one of one sampled resident (Resident 53). This failure had the potential to result in delayed treatments and services for the resident resulting in a decline of health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents on oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with professional standards of practice for four of four sampled residents (Residents 17, 30, 42 and 24) by failing to: a. Ensure Resident 17 received continuous oxygen therapy as ordered by the physician. Resident 17's nasal cannula (NC, tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) was left hanging on top of the oxygen concentrator. Resident 17 did not have a care plan developed on the use of oxygen therapy. b. Ensure to label the NC tubing for Resident 30. c. Ensure Resident 42's oxygen tubing was not touching the floor and the nasal cannula prongs were inside the resident's nostrils. d. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician's order for fluid restriction was implemented from 3/1/2025 to 3/15/2025 for one of two sampled residents (Resident 37) reviewed for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) care. This failure had the potential for fluid imbalance for Resident 37 affecting the resident's nutrition, hydration, and general condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered and disposed consistent with the facility's policy and procedure (P&P) on medication administration and disposal of medications and medication-related supplies by failing to: a. Administer Losartan (medication to treat high blood pressure) as ordered during medication pass observation for one of one sampled resident (Resident 45). This failure had the potential to increase the risk of adverse drug reactions and cause harm to the resident. b. Ensure medication destruction occurs in the presence of two licensed nurses for 72 of 72 destructed medications. This failure had the potential to result in medication misappropriation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on preparing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure Kitchen Aide 1 (KA 1) wore a hair net (hair cover) while preparing food in the preparation area for one of one facility kitchen. This deficient practice had the potential for food borne illnesses (infection caused by ingesting contaminated food) to residents who received food from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 4) in accordance with the facility's policy and procedure titled Call Lights. This failure had the potential for Resident 4 not to receive care or receive delayed services to meet the resident's needs and could result in a fall or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Minimum Data Sheet (MDS, a resident assessment tool) was accurately coded to reflect the resident's discharge destination for one of one sampled resident (Resident 51). This failure resulted to inaccurate reporting to the Centers for Medicare & Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Resident 51 not to receive interventions to address specific care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered before medications were documented as given in the Electronic Medication Administration Record (EMAR, a digital system used to track and document medication administration) consistent with the facility's Policy and Procedure (P&P) on medication administration for one of one sampled resident (Resident 38). This failure had the potential for missed medication or medication error for Resident 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 4) who had gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach) received necessary treatment and services as indicated in the facility's policy and procedure (P&P) titled Enteral Feedings. This deficient practice had the potential to result in weight loss for Resident 4 and altered nutritional status that could lead to complications.

Inspectors wroteb. During a review of Resident 42's AR, the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses that included pneumonia (infection that inflames the lung) and type 2 DM. During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 42 was dependent (helper does all of the effort) to staff for toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 42's OSR dated 3/8/2025, the OSR indicated an order for licensed staff to perform Accu-Chek (blood glucose[sugar] monitoring system) one time a day for DM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of 23 resident rooms (Rooms 2, 8, 10, 11, 15 and 16) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice has the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify one of three sampled residents' (Resident 7) Responsible Party (RP- a person who makes decisions for a resident) that the resident had fallen (to suddenly go down onto the ground or toward the ground) while in the care of the facility. This failure had the potential to deny Resident 7's right for her representative to be informed of Resident 7's health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a daily skin assessment for one of one sampled resident (Resident 8) who was at risk of developing skin breakdown and pressure injuries (localized areas of skin damage caused by prolonged or intense pressure). This failure had the potential for Resident 8 to develop skin breakdown and pressure injuries and/or to not receive treatment for skin breakdown and pressure injuries. (Cross Reference F842)

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 8) by failing to accurately document skin assessments in Resident 8's medical record. This failure resulted in Resident 8's medical record to contain inaccurate information and had the potential to affect Resident 8's care. (Cross Reference F684)

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Documentation Principles, to have complete documentation for one of three sampled residents (Resident 1). This deficient practice had the potential to not provide full information regarding a diagnostic service that Resident 1 received and could result in inconsistencies in providing the necessary care and treatment to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate (satisfactory or acceptable in quality or quantity) hydration (process of replacing water in the body through drinking water and eating food with high water content so every cell, tissue, and organ can properly function) for one of two sampled residents (Resident 1) as indicated in Resident 1's Untitled Care Plan (UPC), dated 5/16/2024, and the facility's policy and procedure (P&P) titled, Hydration Management, and Intake (the measurement of the fluids that enter the body) and Output (the fluids that leave the body), by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in condition (COC- a change in the resident's health or functioning that requires further assessment and intervention) for one of two sampled residents as indicated in the facility's policy and procedure (P&P) titled, Significant Change in Condition, by failing to: 1. Ensure LVN 1 notified Resident 1's Primary Physician (PP/Medical Doctor [MD] 2) promptly (punctually [with little or no delay]) when LVN 1 noted Resident 1 struggled (had a hard time) to drink fluids on his (Resident 1's) own and needed encouragement with drinking fluids. 2. Ensure LVN 1 and LVN 2 communicated with MD 2 to obtain a physician's order for monitoring Resident 1's intake and output. These failures resulted in a delay in providing the necessary care and treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe discharge for one of two sampled residents (Resident 1). This deficient practice resulted in Resident 1 being unsafely discharged with nowhere to stay, after being discharged 497 miles away from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective pest control program by not preventing fruit flies (very small flies which eat fruit and rotting plants) from being inside the conference room and the resident's room for one of four sampled residents (Reisdent 2). This deficient practice had the potential to create unsanitary conditions for Resident 2, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of need for two of three sampled residents (Resident 1 and Resident 38) by failing to: a. Ensure Resident 1's call light was within reach. b. Ensure Resident 38's clock was adjusted after Daylight Saving Time (DST, the practice of turning the clock ahead as warmer weather approaches and back as it becomes colder again). The DST was on 3/10/2024. These deficient practices had the potential for Resident 1 not to receive the necessary care and services that could result in fall/accident and Resident 38 not able to know the correct time.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure titled, Advance Directive for two of three sample residents by failing to: a. Provide information regarding Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.) for Resident 38. b. Ensure the AD copy was readily retrievable in Resident 18's medical records (chart). These failure had the potential to result in facility staffs provided medical care and treatment against the Resident 38 and 18's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safety and protection for Resident 24 who had injuries from unknown source for one of one sampled resident by failing to ensure: 1. Staff immediately reported Resident 24's injuries of unknown source no later than two hours to the DPH (Department of Public Health), Ombudsman, and local law enforcement. 2. Staff investigated Resident 24's injuries of unknown source in accordance with facility's policy and procedures (P&P) for resident abuse prevention in the facility. 3. Staff notified the physician and responsible party of Resident 24's injuries of unknown source. These deficient practices compromised Resident 24's safety and protection from abuse in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 3 sampled residents (Resident 25 and 45) receiving oxygen therapy were provided with respiratory care in accordance with the facility's policy and procedure (P&P) titled, Oxygen Administration, and Storage of Oxygen Cylinder, by failing to: a. Ensure Resident 25's nasal cannula tubing (flexible plastic tubing used to deliver oxygen to help with breathing) did not touch the floor and a cautionary sign was posted on Resident 25's door indicating oxygen in use. b. Ensure Resident 45's nasal cannula tubing was labeled and failing to ensure Resident 45's nasal cannula did not touch the floor, and a cautionary sign was posted Resident 45's door indicating oxygen in use. This deficient practice placed Resident's 25 and 45 at risk for infections and compromised the resident's safety.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week from 3/1/24 through 3/15/24 for 12 of 15 days. This deficient practice may affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitizing solution used for cleaning food prepare area had the correct concentration that met industrial standard to prevent possible contamination for one of three sanitizing red buckets. The recommended concentration for cleaning solution was 200 parts per million (ppm), the sanitizing solution the facility used was 100 ppm. This failure had the potential to result in food prepare areas were not sanitized enough causing contamination and food borne illness to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light was within reach for two of two sampled residents (Resident 204,). This deficient practice had the potential to result in the residents being unable to summon health care worker for assistance for care and services as needed.

Inspectors wroteBased on interview and record review, the notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) did not have an informed decision from the resident's representative to pay for non-covered services after Resident 17 was discharged from Medicare Part A and Resident 17 continued to reside in the facility for one of two sampled residents (Resident 17). This deficient practice placed Resident 17 at risk for payment of out-of-pocket costs for non-coverage services while in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its alternating pressure pad (also known as APP mattress, widely used by both hospital facilities and home care users to provide complete relief from or maximum prevention and treatment of bedsores and pressure ulcers[PU, localized damage to the skin and/or underlying tissue, usually over a bony prominence, or related to a medical or other device, resulting from sustained pressure including pressure associated with shear) was in good working condition, the dial knob for weight adjustment was missing for one of one sampled residents (Resident 38). This failure had the potential to result in the reopen of Resident 38's healed/resolved pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and monitor for the presence of sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate an infection or dehydration [fluid deficit]) in the urine for one of one sampled resident (Resident 11) with an indwelling catheter (foley/urinary catheter - a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's policy and procedure (P&P), titled, Indwelling Catheter Use - Indications and the resident's care plan for foley catheter. This deficient practice had the potential to result in Resident 11 to receive no care or delayed care and treatment for a urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff, for one of one day (Recertification Survey Day 1) who were directly responsible for resident care per shift daily and the information was not posted in a prominent location readily accessible to residents and visitors for viewing. This deficient practice of posting inaccurate nurse staffing information could mislead the residents and visitors that may affect the quality of nursing care provided to the residents.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's recommendations for medication regimen review (MRR) for one of five sampled residents (Resident 6). This failure had the potential to result in undesirable or non-therapeutic effect of the medication related to medication therapy for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 24) on a psychotropic drug (any drug capable of affecting the mood, emotions, and behavior) was free from unnecessary medication by failing to ensure: 1. Resident 24's target behavior symptom for anti-anxiety medication (Lorazepam) 0.5 milligram (mg, unit of measurement) was adequately indicated and monitored. Resident 24 was non-communicative, and the resident could not express feelings of anxiety through verbalization or in writing. This deficient practice placed Resident 24 at risk for adverse drug reactions (a harmful and unintended response to a medicine).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of one sampled resident (Resident 254), the resident's intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) site was labeled with the date and time the IV was inserted. This failure had the potential to result in Resident 254 acquiring an infection that could worsen the resident's health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for six of twenty-three resident rooms (Rooms 2, 8, 10, 11, 15 and 16). This deficient practice had the potential to impact the ability to provide safe nursing care and to provide privacy to the residents residing in the Rooms 2, 8, 10, 11, 15 and 16.