The Pavilion at Sunny Hills

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent for the psychotropic medications and treatments were complete for five of 34 final sampled residents (Residents 3, 6, 9, 69, and 231). * The facility failed to ensure Resident 3's informed consent for the sertraline hydrochloride (antidepressant medication), mirtazapine (antidepressant medication), Ativan (antianxiety medication), and Ativan-Benadryl-Haldol (ABH, antipsychotic medication) medications included the behavioral manifestation related to the use of the medications per physician's orders. In addition, the facility failed to ensure the informed consent for Resident 3's Ativan (antianxiety) medication included the duration for the use of the medication per physician's order. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary services on the formulation of an advance directive was provided for four of seven final sampled residents (Residents 41, 225, 231, and 232) reviewed for advance directive. * The facility failed to follow up the advance directive status after providing the educational materials to Residents 41, 231, and 232 and/or the residents' representative. In addition, the facility failed to ensure assistance in the formulation of an advance directive was offered to Residents 41, 231, and 232. * The facility failed to provide Resident 225's representative with the written information regarding the rights to formulate an advance directive. These failures posed a risk for not providing the care and services based on the residents wishes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for one of 34 final sampled residents (Resident 226) and four of five residents (Residents 3, 6, 9, and 69) reviewed for unnecessary medications. * The facility failed to ensure nonpharmacological interventions were provided prior to the use of Ativan (antianxiety), mirtazapine (antidepressant), and sertraline (antidepressant) medications for Resident 3. The facility failed to ensure Resident 3 was monitored for side effects related to the use of the mirtazapine medication. In addition, the facility failed to ensure the behavior related to the use of the sertraline medication was monitored for Resident 3. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review the facility failed to timely notify and accurately sent the Notification of Proposed Transfer/Discharge to the Office of the State Long-Term Care (LTC) Ombudsman, notified the resident's representative in writing of the reason for transfer and/or bed hold for two of 34 final sampled residents (Residents 49 and 98) and three of three sampled residents (Residents 221, 222, and 223) reviewed for closed records.* The facility failed to ensure the notification of proposed transfer was sent to the Ombudsman for Residents 49, 221, 222, and 223.* The facility failed to ensure Resident 98's family member was notified in writing of reason of transfer to the acute care hospital and bed hold; and the copy of transfer was sent to the Ombudsman. [...]

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for six of 34 final sampled residents (Residents 6, 7, 9, 201, 222, and 230). * The facility failed to ensure the insulin administration sites were rotated as ordered by the physician for Residents 6, 7, 9, and 230. This failure had the potential to result in ineffective treatment, altered medication effectiveness/absorption, and tissue damage. * The facility failed to ensure Resident 201's Lovenox (anticoagulant medication) and insulin injection sites were rotated as ordered by the physician. This failure had the potential to result in ineffective treatment, altered medication effectiveness/absorption, and tissue damage. [...]

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary care and services related to GT enteral feeding for four of 34 final sampled residents (Residents 12, 49, 117, and 148) reviewed for tube feedings. * The facility failed to ensure the GT enteral feeding formula was labeled with the start time for Resident 12. * The facility failed to ensure Resident 49 was administered with the complete dose of the GT enteral feeding as per the physician's order. In addition, the facility failed to label Resident 49's enteral feeding formula with the start time. * The facility failed to ensure Resident 117 was administered with the complete dose of the GT enteral feeding as per the physician's order. * The facility failed to ensure Resident 148's enteral feed syringe was changed daily. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for 10 of 34 final sampled residents (Residents 3, 5, 10, 68, 106, 164, 224, 225, 227, and 231) and one nonsampled resident (Resident 236). * The facility failed to ensure Resident 3's oxygen tubing and storage bag were changed every seven days. * The facility failed to ensure Resident 5's oxygen tubing and nebulizer tubing were changed every seven days. In addition, the facility failed to ensure the nebulizer tubing was inside a storage bag when not in use. * The facility failed to ensure Resident 10 was administered with the oxygen therapy as ordered by the physician. * The facility failed to ensure Resident 68 was administered with the oxygen therapy as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for four of 34 final sampled residents (Residents 6, 201, 227 and 228) reviewed for dialysis services. * The facility failed to ensure Resident 6's left upper arm dialysis shunt was being monitored for bruit and thrill. Additionally, the facility failed to ensure Resident 6's hemodialysis communication records were complete, and failed to ensure Resident 6's intake and output were accurately monitored. * The facility failed to ensure Resident 201 and 228's's fluid restriction was accurately monitored per physician's order. * The facility failed to ensure the emergency dialysis kit was kept at Resident 227's bedside. [...]

Inspectors wroteBased on observations, interview, facility records review, and facility P&P review, the facility failed to ensure the medications were properly stored for one of 34 final sampled residents (Resident 12), one nonsampled resident (Resident 81), and in two of two medication rooms (Medication Rooms A and B). * The facility failed to ensure the medications were stored according to the manufacturer label in Medication Rooms A and B. * The facility failed to ensure the Anasept (an antimicrobial skin and wound cleanser) was not left on top of Resident 81's television stand in Room A. * The facility failed to ensure the medicine cup containing a white color cream and packet of Calma Plex (anorectal paste - provides soothing relief and external protection for irritated, inflamed perianal skin) were not left in Resident 12's room. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling of food and beverages in the kitchen. * The facility failed to ensure the items in the refrigerator was discarded after the use-by date. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the kitchen utensils and equipment were in good condition. *The facility failed to properly air dry the kitchen equipment. *The facility failed to ensure the temperature monitoring of the food kept in the emergency food supply room. * The facility failed to ensure Dietary Aide 1 performed hand hygiene after wearing disposable gloves in the kitchen and before donning new disposable gloves. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection prevention and control program in accordance with the facility's P&P for three of 34 final sampled residents (Residents 117,154, and 231). * The facility failed to ensure PT Assistant 1 had donned on the proper PPE (gown) during transfer from bed to wheelchair for Resident 117 on enhanced barrier precautions. * The facility failed to ensure LVN 8 observed proper hand hygiene during Resident 231's wound care treatment. * The facility failed to ensure facility staff did not keep/store personal belongings in the clean laundry room and no Sani-cloth disinfectant wipe containers being kept with the clean linen. * The facility failed to ensure Resident 154's urinary catheter drainage bag was not touching the floor. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating conditions for one of 34 final sampled residents (Resident 231) and three nonsampled resident (Resident 52, 171, and 235). * The facility failed to ensure Resident 52 and 231's the oxygen concentrator filter was free of thick, dust like particles. This failure had the potential to negatively affect the residents' respiratory health. * LVNs 4 and 11 used the non-facility issued automatic BP machines to take Resident 171 and 235's BP reading. This failure had the potential for the residents to have inaccurate BP measurements.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 34 final sampled resident (Resident 5) and one nonsampled resident (Resident 108) was assessed for safe self-administration of medications. * The facility failed to ensure Resident 5 was safe to administer the saline nasal spray (medication to relieve nasal congestion) medication found at bedside. * The facility failed to ensure Resident 108 was safe to administer the Salonpas Lidocaine Plus (a topical anesthetic to temporarily numb localized muscle, joint and nerve pain) roll on medication and maximum strength Neuropathy (manage tingling, burning and sharp nerve discomfort in your hands, feet and legs) cream found at bedside. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one or five final sampled residents (Resident 13 ) reviewed for nutrition. * The facility failed to notify Resident 13's physician and the resident's responsible party of the 9 lbs. (12.2%) weight loss from 2/3/26 to 3/4/26. This failure had the potential for Resident 13 to not receive the necessary care and treatment to manage the resident's weight loss and the resident's responsible party to not be aware of the resident's current condition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for two of 34 final sampled residents (Residents 106 and 144). * The facility failed to ensure care plan was developed for Resident 106's use of the CPAP machine. * The facility failed to ensure a care plan was developed to address Resident 144's difficulty in hearing. These failures posed the risk of not providing the residents with the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plan was revised to reflect the residents' current care needs and interventions for two of 34 final sampled residents (Residents 3 and 154). * The facility failed to ensure Resident 3's care plan interventions for the use of the pain medications was revised to include the nonpharmacological interventions as per physician's order. * The facility failed to ensure Resident 154's care plan for the risk for fall was revised to include the use of the pad alarm in bed as per the physician's order. These failures posed the risk for the residents to not receive individualized and person centered care in accordance with their assessed needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 34 final sampled resident (Resident 144) was provided with proper care to maintain resident's ability to hear. * The facility failed to ensure Resident 144's had no difficulty in communication when the hearing aide got lost in the facility. This failure had caused the resident difficulty in communication and potentially cause not to meet her needs and psychosocial harm.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care was provided to prevent the development of pressure injuries for one of two final sampled residents (Resident 231) reviewed for pressure ulcer/ injury. * The facility failed to ensure the LVN (LVN 8) assessed Resident 231's pain prior providing the wound care treatment. This failure had the potential for not providing the necessary care and services and effectively managing the resident's needs.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and P&P review, the facility failed to ensure one of five final sampled residents (Resident 13), reviewed for nutrition, received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to ensure an effective monitoring of acceptable parameters of nutritional status were implemented through systematic approach when Resident 13 experienced severe weight loss. The severe weight loss of nine lbs. in one month was not assessed and monitored timely as per the facility's P&P. In addition, the facility failed to ensure the physician was notified of Resident 13's severe weight loss and poor PO (per orem or by mouth) intake and failed to ensure Resident 13 received the hashbrowns for her morning breakfast meal. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the IV accesses for two of two final sampled resident (Residents 37 and 224) reviewed for IV therapy consistent with professional standards of practice. * The facility failed to ensure Resident 37's PICC line was monitored accurately when the facility failed to measure IV line on insertion site and arm circumference as ordered.* The facility failed to ensure Resident 224's peripheral IV was correctly labeled and dated. These failures posed the risk for Resident 37 and 224 to develop complications related to the IV therapy.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary pain management care and services for three of five residents (Residents 3, 6, and 69) reviewed for unnecessary medications. * The facility failed to ensure the nonpharmacological interventions were provided and documented prior to administering the pain medications to Residents 3, 6 and 69. These failures posed the risk for the residents to receive unnecessary pain medications and negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure safe and effective pharmaceutical services was observed for one of 34 final sampled residents (Resident 148) and two nonsampled residents (Residents 120 and 171).* The facility failed to ensure LVN 10 flushed Resident 148's GT (gastrostomy tube) with 30 ml of water after the final medication administration as per the physician's order and the facility policy. This failure had the potential to affect the resident's well-being by not being given the prescribed GT flushes during medication administration.* The facility failed to ensure Resident 120's pregabalin (controlled substances medication) was wasted/disposed of by two licensed nurses in accordance with the facility policy. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 34 final sampled residents (Residents 3 and 228) was free from the unnecessary medications. * The facility failed to ensure the monitoring for the signs and symptoms of bleeding was completed related to use of apixaban medication (anticoagulant, use to prevent blood clots) to Resident 3. * The facility failed to follow the physician's order to hold the carvedilol and nifedipine (medications to treat high blood pressure) medication when Residents 228's systolic blood pressure was below 110 mmHg. These failures had the potential for the residents to receive unnecessary medications and develop significant side effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12% when the prescribed medications were not administered to two residents (Residents 148 and 171) during two of five medication administration observation. * The facility to administer the riluzole (medication used to change the activity of certain natural substances in the body that affect nerves and muscles) and cyclosporine (an immunosuppressant medication) medications to Resident 148. * The facility failed to administer the ferrous sulfate (iron supplement) medication to Resident 171. These failures had the potential risk for the residents to experience adverse clinical outcomes, complications, and disease progression.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for 16 residents who received a pureed diet of 168 residents who receive food from the kitchen.* The facility failed to ensure the pureed tamale pie recipe was followed. This failure had the potential to not meet the residents' nutritional needs and negatively impact the residents' nutritional health.

Inspectors wroteBased on interview and the facility's assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) review did not address or include a contingency plan for the facility staffing needs. These failures placed the residents at risk for unmet care needs if their assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for five of 34 final sampled residents (Resident 37, 226, 227, 228, and 230) were complete and accurately documented. * Resident 37's IV MAR for was incomplete and/or inaccurate. * The facility failed to ensure copy of the Advance Directive for Resident 226 was correct. In addition, the copy of the DPOA for property management was found on the medical record. * The facility failed to ensure Resident 227 and 228's blood pressure access site was accurately documented in the medical record. * Resident 230's advance directive and POLST (Physician Orders for Life-Sustaining Treatment) form did not match. These failures have the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of two final sampled residents (Resident 10) reviewed for hospice services. * The facility failed to ensure the hospice visitation monthly calendar for June 2026 was completed to show the scheduled visits by the hospice skilled nurse. In addition, the facility failed to ensure the hospice visit notes were available in the resident's medical record for June 2026. These failures posed the risk for delay in communication and/or uncoordinated medical care between the facility and hospice provider which may affect Resident 10's care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan was initiated upon admission for one of 34 final sampled residents (Resident 225). * The facility failed to ensure the baseline care plan was initiated for Resident 225 use of the oxygen. This failure put Resident 225 at risk of not receiving resident-centered care.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of eight sampled residents (Resident 5) reviewed for accidents. * The facility failed to ensure two staff performed Resident 5's transfer to her bed while using a mechanical lift. * The facility failed to notify Resident 5's physician when the resident reported hitting her neck and/or head during a mechanical lift transfer experiencing pain. In addition, the facility failed to document and monitor the resident for potential injury. These failures had the potential for Resident 5 not to receive the necessary care and services to maintain the highest physical well-being.

Inspectors wroteBased on observation and interview, the facility failed to follow infection control standards for one of eight sampled residents (Resident 7). * The facility failed to ensure Resident 7's floor mat was stored properly. The floor mat was temporarily propped up against the side of the resident's bed, with the surface of the mat touching the bed linen. This failure placed the risk for contamination of Resident 7's bedding and the potential spread of microorganisms, increasing the risk of infection.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care were revised to reflect the specific care needs for one of seven sampled residents (Resident 1). * The facility failed to revise Resident 1's care plan problem for a heart monitoring device. * The facility failed to revise Resident 1's care plan problem for urinary retention. * The facility failed to revise Resident 1's care plan problem for rectal bleeding. These failures placed the resident at risk to not receive the necessary care to safely maintain the resident's physical well-being.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 1). * The facility failed to follow the physician's order to perform I/O (in and out), for PVR (post volume residual) greater than 250 cc for Resident 1; * The facility failed to notify the physician about Resident 1 was still retaining urine on 1/18/26, and the procedure to perform I/O for a residual of 337 cc was not performed; and * The facility failed to monitor Resident 1 after the resident was identified to have retained urine on 1/18/26. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of seven sampled residents (Resident 1) identified with weight loss. * The facility facility failed to address Resident 1's significant weight loss of seven lbs. in nine days, then five lbs. weight loss eight days after, totaling 12 lbs. weight loss in less than a month. This failure had the potential to result in continued nutritional decline and negative outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive plan of care to reflect the individual care needs for one of three sampled residents (Resident 1). * Resident 1 had a change of condition on 1/31/26, showing the resident's daughter reported to the licensed nurse a CNA was unable to meet the resident's needs and harassing the resident. However, there was no care plan developed to address the resident's daughter's allegations. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 1 and placed the resident at continued risk of danger and/or harm.

Inspectors wroteBased on observation, interview, medical record and facility document review, the facility failed to provide respiratory care services for two of six sampled residents (Residents 2 and 3). * The facility failed to ensure Resident 2's nebulizer mask and tubing was bagged and labeled with the resident's name and date. In addition, the facility failed to ensure the oxygen in use signage was placed on the outside of Resident 2's door. * The facility failed to ensure Resident 3's oxygen tubing was properly stored when not in use. In addition, the facility failed to ensure oxygen in use signage was placed on the outside of Resident 3's door. These failures had the potential for the residents to not receive the appropriate respiratory care, increase the risks of infection and negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 2) was free from unnecessary restraints. * The facility failed to ensure there was a physician's order and informed consent for the use of a lap buddy and pressure pad alarm for Resident 2's wheelchair. Additionally, there was no care plan developed for the use of the lap buddy and pad alarm. These failures posed the risk of compromising the resident's independence and psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for two of five sampled residents (Resident 2 and 3). * The facility failed to ensure Resident 2's abnormal Neurological Assessment

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report an allegation of abuse to the Administrator of the facility, CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement in a timely manner for one of four sampled residents (Resident 10) reviewed for abuse allegations. * The facility's staff reported allegations of abuse to the administrator of the facility, CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement, around eight hours after the staff from the Acute Care Hospital had voiced concerns about Resident 10's allegation of abuse and mistreatment in the facility. This failure had the potential to delay the investigation of the alleged abuse and for the staff not to take prompt and appropriate corrective actions to prevent the alleged abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medication administration was documented for one of three sampled residents (Resident 1). This failure had the potential for the medical record information to be not accurate for Resident 1.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen and resident food storage areas. * The facility failed to ensure the resident carafes were air dried. * The facility failed to ensure the food in the cold and dry storage areas were labeled, dated, and the expired items were thrown out. * The facility failed to ensure the food preparation equipment was clean and free from damage. * The facility failed to ensure the freezer in Refrigerator A, located in Dining Room A and Refrigerator B, located in Dining Room B were monitored for the temperatures and recorded in the temperature log. * The facility failed to ensure the resident's food items in Refrigerators A and B were properly labeled and dated. [...]

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 8) was provided with the necessary care in the manner which promoted dignity and respect. * The facility staff failed to knock and request for permission before entering Resident 8's room. This failure resulted in the resident feeling exposed and disrespected.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to determine and clarify whether two of four final sampled residents (Residents 123 and 785) reviewed for advanced directives had formulated an advance directive for healthcare. * Resident 123's medical record showed conflicting documentation as to whether the resident had formulated an advance directive. * The facility failed to determine if Resident 785 had formulated an advanced directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Level I PASRR contained accurate information for two of two final sampled residents (Residents 92 and 135) reviewed for PASRR screening. * Resident 135 had a diagnosis of unspecified psychosis (a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality) and major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and other symptoms that significantly impair daily functioning) and was prescribed olanzapine (an antipsychotic medication); however the Level I PASRR showed Resident 135 had no serious mental illness and was not prescribed any psychotropic medications. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed or implemented for three of 35 final sampled residents (Residents 13, 80, and 143). * The facility failed to implement Resident 143's care plan specific to the PICC line management. * The facility failed to develop a care plan problem to address Resident 13's use of an e-cigarette and safe smoking practices. * The facility failed to develop a care plan problem addressing Resident 80's LUA midline catheter use. These failures placed the residents at risk for not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for two of 35 final sampled residents (Residents 44 and 77). * The facility failed to ensure the TLSO brace was applied to Resident 44 as per the physician's order. * The facility failed to ensure Resident 77's physician was notified when the resident had the blood sugar levels between 351- 400 mg/dL as ordered. These failures had the potential to affect Resident 44 and 77's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 13) and one nonsampled resident (Resident 40) remained free from accidents and hazards. * Resident 40's room had items cluttered on multiple surfaces of her room, including the floor. This failure had the potential for injury related to resident care and obstacles when a quick and safe evacuation of the resident was needed in an emergency. * The facility failed to ensure Resident 13 was evaluated to determined if the resident required supervision and could safely store their own e-cigarette. These failures had the potential to put the residents at an increased risk for serious injuries and negative health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff provided the necessary care for one of three final sampled residents (Resident 985) reviewed for indwelling urinary catheter (a flexible tube that drains urine from the bladder) use. * The facility failed to ensure Resident 985's suprapubic indwelling urinary catheter bag was placed below the bladder and covered with a privacy bag. This failure had the potential to result in inadequate care and risk for adverse complications for the residents with an indwelling urinary catheter.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to timely respond and follow up on the weight loss for one of four final sampled residents (Resident 169) reviewed for nutrition. In addition, the facility failed to review the resident's nutritional status during the weekly weight management IDT meetings. These failures had the potential for adverse nutritional outcomes and to negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the PICC line assessments were performed and documented for two of two final sampled residents (Residents 80 and 143) reviewed for IV management. * The facility failed to ensure the nurse obtained measurements of Resident 143's arm circumference and PICC line external catheter length in accordance with the physician's orders and the facility's P&P. * The facility failed to ensure the arm circumference and external catheter length measurements were measured on admission and during the PICC line change for Resident 80's PICC line. These failures posed the risk for the residents developing complications related to the use of the PICC line.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of four sampled residents (final sampled residents, Residents 109, 143, and 155) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Resident 109 received the continuous oxygen therapy via the nasal cannula (flexible tube to deliver oxygen into the nose) as per the physician's order. In addition, the facility failed to ensure the nasal cannula oxygen tubing was not touching the floor mat on the ground. * Resident 143's nebulizer oxygen tubing was improperly stored, having been found lying on top of a sock on the resident's end table. * The facility failed to ensure a physician's order was obtained for Resident 155's use of oral suctioning equipment. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of two final sampled residents (Residents 18 and 69) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Residents 18 and 69 and administer the pain medications according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions for pain were provided to Residents 18 and 69 prior to the administration of the pain medications as per the physician's order. These failures had the potential to put Residents 18 and 69 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 35 sampled residents (Resident 60) and two nonsampled residents (Residents 73 and 685). * The facility failed to ensure Resident 73's omeprazole (acid reflux medication) medication bottle was shaken well prior to administering the medication as per the instruction on the bottle. * The facility failed to ensure the narcotic medication for Residents 60 and 685 were accurately signed out and documented as per the facility's P&P. These failures had the risk for negative health outcomes to the residents and the potential to result in medication diversion (the illegal use or distribution of a prescription medication that was not originally intended by the prescriber) and unsafe handling of the narcotic medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 81) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the amlodipine, metoprolol, and hydralazine (antihypertensive medications) medications when Residents 81's systolic blood pressure (the top number in a blood pressure measurement) was less than 110 mmHg. This failure had the potential for Resident 81 to develop significant side effects.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure six of seven final sampled residents (Residents 9, 56, 69, 135, 155, and 985) reviewed for the unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 69's orthostatic blood pressure was monitored for the use of the quetiapine (antipsychotic) medication as per the care plan. In addition, the facility failed to implement the non-pharmacological interventions for Resident 69's observed behaviors for the use of the quetiapine and sertraline (antidepressant) medications. * The facility failed to ensure Resident 135's orthostatic blood pressure was accurately monitored as ordered by the physician and per the care plan, for the use of the olanzapine (antipsychotic) medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications as evidence by the following: * The facility failed to ensure the oral and suppository medications in Medication Cart D were stored separately. * The facility failed to ensure the opened and expired medications and medical supplies in Medication Cart E were properly disposed. * The facility failed to ensure the expired medical supplies were removed from Medication Room B. * The facility failed to ensure Resident 81 and 95's latanoprost 0.005% (glaucoma medication) eye drops were labeled with the opened date; and failed to discard Resident 95's latanoprost 0.005% eyedrop after the beyond-use by date in Medication Cart C. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 45 of 171 residents who received food from the kitchen received the proper diets when the facility's menu was not followed. * The facility failed to ensure 45 residents who were on CCHO diets (diets for diabetics) and three residents who were on renal diets (specialized diet designed to support kidney health) received the homemade barbeque (BBQ) sauce with their oven BBQ beef roast as per the menu and recipe. This failure had the potential for the residents' nutritional needs not being met, which could result in medical complications.

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for the residents from the outside and family/visitors who brought food for the residents from the outside were educated on safe food handling procedures. This failure posed the risk for food borne illness in residents who consume food from outside sources.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for four of 35 final sampled residents (Residents 56, 80, 81, and 163) and one nonsampled resident (Resident 40). * Resident 81 had conflicting orders for holding Resident 81's enteral feeding via GT, specific to the residuals. * The facility failed to ensure the accurate and complete medical record for Resident 56. * The facility failed to ensure the medication routes for Resident 163 with GT were accurate. * The facility failed to ensure the documentation on the IV MAR was completed for Resident 80. * Resident 40's consult psychiatrist's progress note was not part of the resident's medical record. These failures had the potential for not providing necessary care and services due to inaccurate medical records.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for two of 35 final sampled residents (Residents 143 and 985) and one nonsampled resident (Resident 37) as evidence by the following: * The facility failed to ensure the EBP was maintained for Resident 143 with a PICC line during an IV medication administration observation. * The facility failed to ensure the visitors wore PPE in a contact isolation room for Resident 985. * During the medication administration observation for Resident 37, LVN 6 failed to perform hand hygiene in between glove use. * The clean laundry room had the facility staff's personal belongings and a Sani-cloth disinfectant wipe container with the clean linen. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the facility equipment was maintained in the safe operating condition. * For Medication Cart C, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. In addition, the facility failed to ensure the corrective actions were taken when the quality control results for the glucometer were out of range. * The facility failed to ensure the serial number on the glucometer and on the Quality Control Record matched for Medication Cart B. * The facility failed to ensure the quality control checks were performed for the glucometers in Medication Cart A and B. These failures had the potential risk of inaccuracy for the residents' blood glucose test results.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 115) was safe to self-administer the medications. * The facility failed to ensure the plastic containers filled with Halls Menthol Cough and Throat Relief (cough drop) were not stored in Resident 115's cabinet and bedside table. This failure had the potential for the resident to administer the medication inaccurately, develop adverse reactions from the medication, and negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the residents' privacy was maintained when the confidential resident roster (a list which identified the names of the residents by their, to protect the residents' identities) for the abbreviated survey completed on 10/12/21, was in the survey binder and available for public view. This failure had the potential to result in a violation of the residents' rights in maintaining and upholding confidentiality with the residents' protected health information.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of three sampled residents (Resident 183) reviewed for the closed records. This failure had the potential for inaccurate data submitted for quality measures.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to properly dispose of the discarded cardboard boxes. This failure had the potential to attract rodents and pests that carried a disease.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well -being for one of two sampled residents (Resident 2). * The facility failed to ensure Resident 2 had a physician's order for suctioning as per the discharge order from the acute care hospital. * The facility failed to weigh daily and provide the Lasix medication to Resident 2 as per the physician's instructions. * The facility failed to notify the physician and responsible party of Resident 2's continued refusals of the medications and supplements. * The facility failed to provide Resident 2's indwelling urinary foley catheter care, and wound care treatments as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and the facility P&P review the facility failed to comply with the State laws as evidenced by LVN 3 and CNA 2 not wearing their name badges. This failure had the potential to negatively affect the resident's emotional well-being as they are not able to identify the person providing their care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to follow up with the hospice for the latanoprost eye drop (to treat glaucoma) order for Resident 1. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 4). * The licensed nurse failed to prime Resident 4's Tresiba (insulin pen injection) prior to administering the insulin medication as per the manufacturer's instructions for the use of insulin pen medication. This failure posed the risk for complications related to the resident not receiving the correct amount of the prescribed medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure 10 of 35 final sampled residents (Residents 55, 58, 94, 151, 154, 167, 420, 421, 423, and 425) and three nonsampled residents (Residents 146, 160, and 872) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 154's oxygen nasal cannula (flexible tube to deliver oxygen into the nose) tubing was labeled and dated as per the physician's order. * The facility failed to ensure Resident 425 had a physician's order for administration of oxygen and oxygen nasal cannula tubing was labeled and dated. * The facility failed to ensure Resident 420's nebulizer mask, tubing, and oxygen tubing were labeled and dated. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper labeling and storage of medications according to the facility's P&P and/or manufacturer's specifications when: * Medications were not properly labeled and stored in five of eight inspected medication carts and two of two inspected medication rooms. This deficient practice had the potential for inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents, unsafe and reduced efficacy from being used past their discard date, and medication errors due to medication not being labeled.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen and in patient food storage areas. * The facility failed to ensure food preparation equipment was air dried. * The facility failed to ensure the resident food equipment was stored clean. * The facility failed to ensure the food cutting boards were in good condition. * The facility failed to ensure the resident food in the cold and dry storage areas were labeled and dated. * The facility failed to ensure the resident food in the third floor community refrigerator was labeled and dated. * The facility failed to ensure the food items stored in the residents' personal refrigerator for Residents 146, 160, 520, 870, and 872 were properly labeled and dated. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for four of 35 final sampled residents (Residents 151, 422, 425, and 520) and one nonsampled resident (Resident 110) to self-administer the medication left at the bedside. * Resident 110 was observed with bottles of vitamin B12 (supplement), vitamin E (supplement), fish oil (supplement), vitamin D3 (supplement), and PreserVision (supplement) medications at the bedside. Resident 110 did not have the assessment, physician's order, and care plan problem addressing the resident's self-administration of medication. * A bottle of polymix B sulfate and trimethoprim ophthalmic solution (eye drops antibiotic), a medication cup filled with white cream, and one Dulcolax suppository were observed at Resident 422's bedside table. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain the copy of the advance directive (legal document that stats a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for two of 35 final sampled residents (Residents 91 and 151). This failure had the potential for the resident's decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview, observation, medical record review, facility document review, and facility P&P review, the facility failed to notify and promptly resolve a written filed grievance for one of 35 final sampled residents (Resident 6). Resident 6 had missing personal photos from her room after she was moved to another room and requested for reprinting he photos; however, no staff had followed up with her regarding reprinting her personal photos. As a result of this failure, Resident 6 stated she felt depressed and angry.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for five of 35 final sampled residents (Residents 91, 135, 154, 424, and 520). * The facility failed to develop a care plan problem for Resident 154's use of oxygen and Resident 424's use of PICC line (peripherally inserted central catheter - intravenous access used for a prolonged period of time). * The facility failed to ensure Resident 520's care plan was personalized to address safe smoking practice. * The facility failed to develop and implement a person-centered care plan for Resident 91's buspirone. * The facility failed to develop a care plan problem to address Resident 135's use of bilateral 1/4 side rails. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of two of 35 final sampled residents (Residents 33 and 76). * The facility failed to provide activities for Residents 33 and 76 to meet the residents' identified interests. The facility only provided activity programs to Residents 33 and 76 on 11/9, 11/20, 11/23, and 12/2/23, for November and December 2023. This failure had the potential for the residents to experience feelings of social isolation and frustration.

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 35 final sampled residents (Resident 10). * Resident 10 was not administered hydralazine (antihypertensive; used to treat high blood pressure) medication when the resident's SBP was more than 150 mmHg as per the physician's order. This failure had the potential for Resident 10 to develop health complication from high blood pressure.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident was evaluated for safe smoking practices for one of 35 sampled residents (Residents 520). * Residents 520 was not evaluated to determine if the resident required supervision and could safely store their own cigarettes or lighters. This failure posed the risk for unsafe environment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of final sampled residents (Residents 3 and 76) and one nonsampled resident (Resident 871). * The facility failed to ensure Resident 76 was positioned safely at least 40 degrees during feeding administration via GT as ordered. * The facility failed to ensure Resident 33 was administered the water flush via GT pump as ordered. *The facility failed to ensure Resident 871's enteral formula container was labeled with the time when it was hung, and the water flush container was labeled and dated when hung. These failures posed the risk for developing complications related to GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 35 final sampled residents (Resident 424). The facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 424. This failure had the potential to delay identification of catheter related complications for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for three of 35 final sampled residents (Residents 10, 86, and 126). * The facility failed to ensure the physician's order for 1000 ml fluid restriction (a diet which limits the amount of daily fluid consumption) per 24 hours was followed and carried out accordingly for Resident 126. * The facility failed to ensure the water pitcher was not in Resident 126's room when on a fluid restriction as per the facility's P&P. * The facility failed to ensure the dressing on the dialysis access site was removed four hours after dialysis treatment. Resident 86 was observed with a dressing on the left forearm dialysis access two days after dialysis treatment. [...]

Inspectors wroteBased on observation, interview, facility P&P, and document review, the facility failed to * Ensure accountability for controlled medications (medications that have some potential for abuse or dependence) for one of 35 sampled Residents (Resident 135), when the controlled medication was signed out of the resident's narcotic record but was not documented as administered. This failure had the potential for exposing residents to ineffective treatment, medication errors, and the potential for diversion of controlled medications. * Ensure used refrigerated emergency medication kit was replaced timely. This failure had the potential for medication not to be available when needed, which may result in poor resident's outcome.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for three of 35 final sampled residents (Resident 91, 92, and 135). * The Pharmacy Consultant's recommendation for a duration of therapy for the prescribed heparin (anticoagulant; used to decrease the clotting ability of the blood) medication for Resident 92 was not acted upon. This failure had the potential to put Resident 92 at risk for adverse consequences related to the medication. * The facility failed to ensure the consultant pharmacist identified the medication-related irregularities during the monthly drug regimen review; when adverse effects of lamotrigine medication used to treat mood swings by Resident 91 was not being monitored and it was not identified by the consultant pharmacist. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 35 final sampled residents (Residents 55, 91, 94, and 425) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to monitor the specific behavior manifestation for Resident 94's use of clonazepam (use to treat anxiety). * The facility failed to ensure Resident 55's orthostatic blood pressure (measure the blood pressure while laying down and sitting) was monitored as ordered by the physician related to the use of an antipsychotic medication. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The facility failed to ensure the residents' clothing and blankets from the laundry were transported and delivered in a clean and sanitary manner. The facility failed to ensure the residents' clothing and blankets were inside a fully covered linen cart during transportation. * The facility failed to ensure the staff practiced the contact precaution when entering Resident 75's room that had a posted signage outside the room for contact precaution. In addition, the facility failed to ensure the correct special precautions for Resident 75 were posted. * The facility failed to ensure Resident 925's uncovered urinal was not placed next to a drinking water cup. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately determine whether five nonsampled residents (A, 22, 41, 128, and 159) who were prescribed antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the residents' physicians that the residents did not meet McGeer's criteria for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. This failure had the potential to result in the adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for four of 35 sampled residents (Residents 5, 92, 167, and 422). These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and treatments from the responsible party (person designated to make decisions on behalf of the residents) for one of 35 final sampled residents (Resident 55). This failure posed the risk for Resident 55 and her responsible party to not be informed of her medications and the potential side effects.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medical record was safeguarded to protect the confidential health information for one nonsampled resident (Resident 146). This failure had the potential for the residents' personal and health information to be accessed from the unauthorized users.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 35 final sampled residents (Resident 75) was revised to reflect the resident's current care needs and interventions. The facility failed to ensure Resident 75's plan of care was revised to address the change in the frequency of Resident 75's RNA ROM physician's order. This posed the risk of not providing Resident 75 with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure multiple waste bins were properly contained. This failure had the potential to cause unsafe and unsanitary conditions in the facility.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the second floor microwave used to heat the residents' food was free from brown splash marks, rust, and holes. This failure had the potential to cause foodborne illnesses to the second floor residents who brought food by the family members or visitors.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse when the Activity Assistant yelled, held Resident 1's wristdown, and raised her hand in a fist above Resident 1 in a threatening manner. This failure had the potential to negatively impact the resident's well-being.