The Redwoods Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to maintain infection prevention and control practices to prevent the spread of infection when:Certified nursing assistant (CNA) staff failed to wear a gown (to cover staff's clothing and skin to prevent the spread of infection [part of the personal protective equipment, PPE]) when they transferred a resident with enhanced barrier precautions (EBP, an infection control strategy used with residents with high risk infections or devices in place to prevent the spread of infections or to protect from infections); and,Occupational Therapist (OT, a healthcare expert who helps residents do everyday tasks and gain independence) failed to discard gloves appropriately after removed. These failures had the potential for disease transmission among residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete medical record for one of three sampled residents (Resident 1) when:There were multiple days for which there was no documentation that Resident 1's scheduled skin treatments were provided;There were multiple days for which there was no documentation that Resident 1 was provided assistance for certain activities of daily living (ADLs); andThere were multiple days for which there was no documentation of Resident 1's meal intake (percentage of food the resident ate during each meal). These failures had the potential to compromise the facility's ability to ensure adequate care and monitoring were provided to maintain Resident 1's health and well-being at the highest practicable level.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of 31 sampled residents (Residents 92, 307, and 400) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 92 received four psychotropic medications without documented evidence of attempted or contra-indicated non-pharmacological (non-drug) interventions prior to initiating or increasing these medications. Also, there was no monitoring for side effects of aripiprazole (Abilify, an antipsychotic medication to treat mental illnesses) since July 2024; 2. Resident 307 received a PRN (as needed) prochlorperazine (antipsychotic medication which can be used for short term psychotic disorders or nausea/vomiting) without a 14-day limit; and 3. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility had a medication error rate of 11.11% when three medication errors occurred out of 27 opportunities during the medication administration for three out of seven residents (Residents 81, 118, and 133). The failure resulted in the residents not receiving the medications as prescribed, and had the potential for complications such as unnecessary pain or medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when two of the ceiling exhaust fans above the food preparation area were dirty and dusty with grey lint. These failures had the potential to cause food borne illness for 143 residents consuming food in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two trash dumpsters had the lid closed completely. This failure had the potential to attract pests (like flies and rodents) that could spread diseases and bacteria to the 150 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care for when the individual becomes incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for 3 of 31 sampled residents (Residents 29, 31, and 32). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the residents' goals and wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for one out of eleven sampled residents, (Resident 301), when Resident 301's refusals to participate in the activities that were being offered was not care planned. This failure had the potential to result in the resident not receiving the intervention and monitoring necessary to maintain his highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for two of thirty-one sampled residents, (Residents 8 and 400), when: 1. for Resident 8, there was no care plan, monitoring and follow-up of her hand contractures, and 2. for Resident 400, the staff took the blood pressure (BP, the force of blood pushing against the walls of the arteries) on the same arm where the resident has the AV fistula (arteriovenous fistula, connection that's made between an artery and a vein for dialysis access.) These failures had the potential for the residents, not to attain or maintain their highest practicable physical, mental, psychosocial well-being, and potential to cause injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the adequate provision of pharmaceutical services when: 1. Three medications were not available for administration x 4 days, for one of 36 sampled residents (Resident 311). The failure had the potential for worsening and/or complications of the resident's medical conditions; and 2. Two of two nursing staff did not don appropriate personal protective equipment (PPE) during the preparation and administration of hazardous drugs (HDs; medications with potential to cause cancer and/or for causing other toxic effects on humans). The failure had the potential for staff and/or resident exposure to dangerous medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 400) was free from unnecessary medications when there was no monitoring for signs and symptoms of bleeding while Resident 400 was receiving two medications with increased risk for bleeding: apixaban(an anticoagulant or blood thinner, to prevent blood clots) and clopidogrel (an antiplatelet medication which has potential to increase the risk of internal bleeding or gastrointestinal hemorrhaging). The failure resulted in inadequate monitoring, and had the potential for untimely recognition and intervention for adverse effects related to these medications.

Inspectors wroteBased on interview and record review, the facility failed to provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 3 residents (Resident 1) when the licensed nurse did not obtain pressure ulcer measurements and no treatment order was obtained for 6 days for Resident 1's pressure ulcer. These failures had the potential to delay treatment and potentially lead to new or worsening pressure ulcers. Failure to obtain measurements had the potential to compromise the facility's ability to determine whether Resident 1's pressure ulcer was increasing or decreasing in size.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice prior to multiple room changes for one of four sampled residents (Resident 1). This failure had the potential to compromise Resident 1's rights. Also, there was no documentation that the facility monitored Resident 1 after one room change. This failure had the potential to compromise the facility's ability to identify complications related to the room change and implement interventions accordingly.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS, an assessment tool) for one of four sampled residents (Resident 1). The failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards for one of four residents (Resident 1) when: 1. There were multiple days for which there was no documentation that the facility obtained Resident 1's daily weight as ordered by the physician, and 2. There were multiple days for which there was no documentation that the facility notified Resident 1's physician of an abdominal girth (measurement of distance around the abdomen) increase of more than three centimeters (cm, unit of measurement). These failures had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to develop a comprehensive person-centered care plan (plan that identifies residents' needs and outlines the care and services to be provided to meet those needs) for one of two sampled residents (Resident 1) to address management of onychomycosis (fungal infection of the nails). This failure had the potential to result in Resident 1 not receiving necessary care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by: 1. The facility failed to use the proper disinfectant to disinfect shared (used for multiple residents) glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions and accepted professional standards for 41 of 41 residents when: 1a. Licensed Vocational Nurse A (LVN A) failed to properly disinfect a shared glucometer during observation for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; 1b. Licensed nurses in three out of three nursing stations: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 29 sampled residents (Resident 15, 46) when: 1. Nursing staff failed to clarify an unsafe insulin order for Resident 15, posing a risk of adverse outcomes such as severely low blood glucose (BG, or blood sugar) for the resident; and 2. Nursing staff failed to identify duplicate orders for Resident 46's Seroquel (generic name: quetiapine, an anti-psychotic medication to treat mental illnesses), resulting in Seroquel given in excess and more than prescribed for two months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice. Seven nursing staff in three out of three nursing stations, the director of nursing (DON), and the Infection Preventionist/Director of Staff Development (IP/DSD) did not know about the appropriate disinfectant product to use and/or the allowance of wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect) when disinfecting shared glucometers. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Four of four controlled drug sign-in/sign out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart) by the incoming and outgoing nurses during a shift change were missing signatures; 2. Random as-needed controlled medication use audits for three of five sampled residents (Residents 13, 14, and 139) did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications), but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 25 opportunities during the medication pass resulted in three errors. The calculated medication error rate was 12 percent. These failures placed Residents 9 and 25 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the physician's orders and/or the manufacturer's specifications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 29 sampled residents (Residents 9 and 46) and Residents 13, 25, 45, and 250 were free of a significant medication errors when: 1. Five residents (Resident 9, 13, 25, 45, and 250) received insulin past the discard (expiration) date. These failures had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the residents; and, 2. Resident 46 received excessive doses of Seroquel (generic name quetiapine, an antipsychotic medication to manage mental illnesses) more than prescribed for 2 months. This had the potential for the resident to suffer severe adverse effects such as excessive sedation, drowsiness, blurred vision, loss of appetite, urinary retention, low blood pressure, seizure, diabetes, and abnormal involuntary movements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications in three of three medication carts inspected and one of two medication rooms inspected when: a) Medication Cart 3B contained eight (8) expired medications, two (2) opened medications without an open date label, and two (2) test strip (thin plastic strips which measures blood sugar levels) vials opened without an open date label; b) Medication Cart 1A contained two (2) expired medications, four (4) opened medications without an open date label, and one (1) test strip vial opened without an open date; c) Medication Cart 2A contained two (2) expired medications and two (2) opened medications without an open date label; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food services safety when: 1. Resident 139's opened condensed milk (a sweetened cow's milk product) was not properly labeled and stored in the refrigerator (Cross reference F813), 2. An unlabeled bucket of white powder was in dry storage, 3. Cutting boards with deep cuts with stains, food residuals and and loose plastic particles were found on a clean storage rack, 4. A can opener had black matter on its cutting surface, and 5. A serving scoop storage drawer contained crumbs and orange matter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for residents when: 1. Bed side rails were not stable or installed properly; 2. Toilet doorknobs were either missing, broken and/or loose, and a tissue holder was broken; 3. A Doorknob was missing and a tissue holder broken; 4. Cabinet drawers were broken and a tray table had chipped paint and chipped edges; 5. A bathroom door was out of order and had stains; 6. Four bed footboards were loose; 7. Window blinds were broken; 8. The Bathroom of Room F lacked a door. These failures had potential to compromise residents' safety, well-being and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for three residents (Residents 3, 31, and 41). 1. For residents 3 and 41 staff provided feeding assistance while standing. 2. For resident 3, staff did not provide privacy during therapy treatment. These failures had the potential to negatively affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 145) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services.

Inspectors wroteBased on observation and interview, the facility failed to maintain a organized and sanitary environment for one non-sampled resident (Resident 116) when the room was disorganized, her tray table used for meals had chipped areas, and one wooden cabinet drawer was broken. These failures created a disorganized and unsanitary environment that could pose safety risks for Resident 116 .

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman (organization that advocates for the residents) when four of four sampled residents (Residents 6, 135, and 146) were transferred to the acute care hospital or discharged from the facility without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, a comprehensive assessment tool) discharge assessment in a timely manner for one of 29 sampled residents (Residents 126). This failure resulted in the resident's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System within the time requirement.

Inspectors wroteBased on interview and record review, the facility failed to accurately code in the MDS (Minimum Data Set- an assessment tool) for three of 29 sampled residents (Resident 103, 108 and 90) when the completed and transmitted MDS did not include: 1. Resident 103's three fall incidents, one of which resulted in minor injury. 2. Resident 108's functional limitation on one side of an upper extremity. 3. Resident 90's special treatments and procedures. These ommissions in coding resulted in an inaccurate MDS.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement individualized, resident-centered care plans for three of 29 sampled residents when care plans for: 1. bilateral upper side rails for Resident 6 were not followed, 2. risk for fall/further falls (to provide floor mat and keep bed in lowest position) was not followed for Resident 66, 3. skin discoloration was not developed for Resident 107. The failure to developed and/or follow care plans had the potential unmet care needs for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three sampled residents (Residents 59, 90, and 122) when: 1. For Resident 90, there was no documentation or monitoring of the cardiac defibrillator. 2. For Resident 59, licensed nurses did not follow the physician's order and care plan to use the bed's 1/4 bilateral upper side rails up. 3. For Resident 122, licensed nurses did not follow the physician's order to administer the medication Niacin (B vitamin that's made and used by the body to turn food into energy) with meals. These failures had the potential to compromise the resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for a suprapubic catheter (SPC, a type of catheter that is inserted through a hole in an abdomen [tummy] directly to the bladder [the organ that stores urine] and left in place) when (1) Resident 93's SPC site was unclean and (2) the urinary drainage bag was not changed as ordered. This failure in care had the potential for the patient to develop a urinary tract infection (UTI, an infection caused by a bacteria (germs) that get into the bladder or kidneys (a pair of organs that are on either side of the spine, just below the rib cage of a person's back).

Inspectors wrote2. Review of Resident 90's clinical record indicated he was admitted on [DATE] with diagnoses including end stage renal disease (kidney failure, kidneys no longer function to meet the body's needs), dependance on renal dialysis (dialysis: a procedure in which a machine filters wastes and fluid from the blood), congestive heart failure (condition when the heart cannot pump and fill adequately), and obesity. Resident 90 was scheduled for dialysis every Monday, Wednesday, Friday, and Saturday. Resident 90's had an arteriovenous fistula (AVF, surgically created connection between an artery and vein to allow dialysis to occur) in his left forearm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure person-centered care and services for one of eight residents (Resident 248), when a negative behavior was not care planned or monitored. This failure had the potential of a decline in Resident 248's physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility's consultant pharmacist (CP) failed to identify and report to the facility irregularities in the residents' monthly drug regimen review (DRR) for two of 29 sampled residents (Residents 15 and 32). Undetected medication irregularities had the potential for unsafe medication use and/or residents not achieving highest therapeutic outcomes. Findings; 1. During a medication administration observation on 2/7/23 at 12:31 p.m., Licensed Vocational Nurse L (LVN L) was observed pricking Resident 15's right ring finger to obtain a blood sample to measure his blood glucose (BG) level. The BG reading was 142 milligrams/deciLiter (mg/dL, unit of measurement; normal BG is less than 100 mg/dL) at this time. LVN L stated Resident 15 needed 6 units of insulin (medication to lower BG) for the BG reading of 142 mg/dL. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 29 sampled residents (Resident 46) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior). Resident 46 received Seroquel (generic name quetiapine, an antipsychotic medication to manage mental illnesses) in excessive doses, higher than prescribed, for 2 months. This failure had the potential for the resident to suffer severe adverse effects such as excessive sedation, drowsiness, blurred vision, loss of appetite, urinary retention, low blood pressure, seizure, diabetes, and abnormal involuntary movements.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a policy to ensure safe and sanitary storage, handling, and consumption for the food brought in by family when Resident 139's room had multiple unlabeled open food items. This failure had the potential to limit the resident rights and enjoyment of the food brought in by the family (Cross reference F812).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 8/13/19 menu was followed. This failure could result to resident's dissatisfaction to the food served and dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions when: 1. There were five uncovered deli containers filled with salad dressing; 2. The kitchen drawer used to put kitchen utensils had reddish yellowish flaky color substances; 3. The can opener had a black substance; 4. The walk in refrigerator condenser fan cover had grayish substance; 5. Fruit cocktail was uncovered in the preparation sink area and the dietary aide R (DA R) disposed the quaternary solution in the preparation sink; 6. DA R did not demonstrate the proper procedures for testing the strength of sanitizer used for sanitizing food contact surfaces; 7. Quaternary ammonium log policy was not implemented; 8. The dishwasher log was not completely filled out. [...]

Inspectors wrote8. During a kitchen observation on 8/12/19 at 3:35 p.m., maintenance staff Q (MS Q) washed his hands in the food preparation sink. MS Q confirmed observation and stated he should wash hands in the sink designated for hand washing. According to the FDA Food Code 2017 as specified in paragraph 2-301.15 indicated sink used for food preparation may not be used for handwashing. Based on observation, interview and record review, the facility failed to maintain proper infection control practices when: 1. Resident 390's oxygen nasal cannula (NC) tubing (a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils) was undated and was touching the bedside table; 2. Resident 66's unlabeled oxygen nasal cannula prongs and tubing was exposed, hanging and touching to the wheel of the wheelchair; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP) for one of 27 sampled residents (Resident 78) when Resident 78 was transferred to an acute hospital. This failure had potential to result in Resident 78 receiving inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for one of 27 sampled residents (Resident 100) when Resident 100 had episodes of orthostatic hypotension (a form of low blood pressure that happens when changing position, such as standing up from a sitting or lying down position, this can cause dizziness or lightheadedness, or fainting). This failure had potential to result in Resident 100 at risk for fall .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and homelike environment when the carpet in the dining/activity area door was protruding (stick out) . This failure had the potential to be harmful for residents who were going to the dining/activity room.

Inspectors wroteBased on interview and record review, the facility failed to document that family or responsible party (RP) was notified for one of 27 sampled Resident (Resident 124) when Resident 124 was sent from her wound care clinic appointment to acute hospital and was discharged from the facility. This failure had potential to affect Resident 124's medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 27 sampled residents (Resident 113) when the resident had an indwelling catheter (surgical procedure to drain urine from the bladder into a drainage bag) and had significant weight loss. These failures had the potential to result in Resident 113 unable to achieve or maintain optimal status of health, function and quality of life.

Inspectors wrote3. Review of Resident 55's clinical record indicated he had diagnoses including altered mental status (change in brain function that can cause confusion or sleepiness). Resident 55 had four falls in the facility. Review of Resident 55's fall notes, dated 5/5/19 indicated Resident 55 tried to get a shirt from his closet and slipped when trying to get up. It indicated a new intervention to prevent reoccurrence of a fall was to provide Resident 55 with a grabber tool to prevent overreaching for items. During an observation and interview on 8/15/19 at 7:34 a.m., unit manager A (UM A) was unable to find the grabber tool in Resident 55's room. UM A stated Resident 55 should have a grabber tool. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide quality care and services for three of 27 sampled residents (Residents 42, 98 and 99) when: 1. Resident 98 had a diagnosis of diabetes mellitus (DM, a condition which affects the way the body processes blood sugar) and licensed nurses did not properly manage an episode of hyperglycemia (high blood sugar). 2. Resident 99 had a change of condition and nursing staff failed to adequately monitor the resident up to the time she was transferred to an acute care hospital. 3. Resident 42 had a generalized red, itchy rash and nursing staff did not provide appropriate incontinence care when paper towels were used. These failures had the potential to cause health complications to Resident 98 and 99, and to cause discomfort to Resident 42.

Inspectors wroteBased on interview and record review, the facility failed to prevent accidents for one of 27 residents (Resident 83) when the interdisciplinary team (IDT- group of different disciplines that meet to discuss and review resident care needs) When Resident 83 fell three times in the facility and the IDT did not discuss and evaluate the root causes for these falls. This failure resulted in Resident 83's multiple falls and one fall resulted with lower inner lip laceration.

Inspectors wroteBased on interview and record review the facility failed to ensure staff had coordinated residents' care with the dialysis facilities for two of two sampled residents receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte i.e. salts and mineral imbalances by using a machine and an artificial kidney) for Residents 78 and 380 when: 1. Resident 78 had two physician's orders indicating different amounts of fluids he was allowed to consume and his care plan was not revised to indicate his dialysis access site and care had changed. 2. Resident 380 had incomplete communication between the facility and dialysis center. This failure had the potential to result in a break with continuity of care and in causing resident health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely replace one of 13 emergency kits (E-Kit, emergency medications that needed for immediate administration) medications from the provider pharmacy. This failure had the potential to cause delay in treatment and compromise residents' medical health.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 27 sampled residents (Resident 39) was free from unnecessary drugs when Resident 39's A1C (A1C test result reflects the average blood sugar level for the past two to three months) laboratory sample was not drawn for monitoring. This failure had the potential affect Resident 39's medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a pureed diet was provided to one of 27 sampled residents (Resident 116) per order when the certified nursing assistant B (CNA B) assisted fed Resident 116 with regular scrambled eggs and bacon during breakfast. This failure had the potential to prevent meeting Resident 116's special dietary needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was disposed properly when one of three facility dumpsters lid was left opened. This failure had the potential to result in spread of disease from vermin infestation and unsanitary environment for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate care with a hospice provider (service that provides care for the sick or terminally ill) for one of one sampled resident (Resident 99) who was on hospice services. There was no hospice calendar and facility staff did not follow-up on hospice notes of Resident 99's desire to change her diet and a black discoloration of her right foot. These failures had the potential of not meeting the needs or not improving the quality of life for the resident.