The Rehabilitation Center of Bakersfield

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when:1. One can of roasted diced tomatoes was dented.2. Multiple food items were expired in dry storage room.3. Cauliflower and cabbage were expired in the walk-in refrigerator.4. Multiple food items were uncovered and undated in the walk-in freezer.5. One freezer containing partially melted ice cream was not maintained at the required temperature for frozen food storage.6. One cook did not wear a hair restraint while in the kitchen.7. C-wing's ice machine chute (the passage where ice travels down into a storage bin) was visibly dirty. These failures posed the risk of food borne illness in a medically fragile resident population of 146 facility residents who received food prepared in the kitchen and ice after the closing of the kitchen.

Inspectors wroteThe facility failed to implement and maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of disease and infections when: 1. Resident 40 was not properly assessed for susceptibility or risk factors prior to being cohorted (group of people who share a room) with Resident 152 who was confirmed to have herpes zoster (shingles- contagious painful, blistering rash). This failure had the potential to result in an avoidable transmission of a communicable disease and potential health complications to Resident 40. 2. a. There was no signage posted outside the room to indicate which resident required transmission-based precaution (TBP-either as standard precaution, contact precautions, droplet and airborne) in Rooms 316. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 29 sampled residents (Resident 9) was treated with dignity and respect, when Resident 9 used her call light to request assistance and did not receive staff assistance for approximately 45 minutes. This delay in response demonstrated a lack of respectful and dignified care and had the potential to negatively impact the resident's self-esteem. Resident 9 stated the delay in assistance was disrespectful. During a review of Resident 9's face sheet (a document containing demographic and admission information), it was noted that the resident was admitted to the facility on [DATE]. The documented diagnoses upon admission included Parkinsonism (a slowly progressive neurological disorder characterized by the gradual loss of dopamine-producing nerve cells in the brain) urinary tract infection, and a history of falls. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the residents' disposable care equipment (emesis basin, urinal, and urine collection containers) was maintained in a clean, sanitary and safe manner. The disposable care equipment's were found unlabeled, undated and uncovered in multiple residents' bathroom and at bedside. This deficient practice had the potential to expose residents to cross contamination and risk for infection.

Inspectors wroteBased on an interview and record review, the facility failed to inform the Office of the State Long-Term Ombudsman (SLTO - independent advocate for residents in nursing homes) when one of three sampled residents (Resident 159) was transferred urgently to the general acute care hospital (GACH) and subsequently discharged from the GACH to an assisted living. This failure had the potential for Resident 159 to not receive the proper oversite, protection, and advocacy of the Office of the State Long-Term Ombudsman regarding continuity of care for future medical needs. During a review of Resident 159's admission Record (AR), dated 1/15/2026, the AR indicated that Resident 159 was admitted on [DATE] for management of an infection requiring intravenous (IV - medication administered directly into a vein) infusion of an antibiotic (medication used to treat infection). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) for one resident (Resident 13) accurately reflected her clinical status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) for Resident 13. During a review of Resident 13's undated admission Record , it indicated Resident 13 was admitted to the facility on [DATE] with a diagnosis that included: Hypertensive and chronic kidney disease with heart failure and stage 5 chronic disease, or end stage renal disease (high blood pressure has significantly damaged the kidneys and heart, leading to kidney failure (Stage 5/ESRD), requiring dialysis or transplant, and often accompanied by heart failure), and dependence on renal dialysis. During a concurrent interview and record review on 1/14/2026 at 10:10 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure baseline comprehensive, person-centered care plans were developed and implemented for one of 29 sampled residents (Resident 44) when:1. Resident 44 did not have a care plan to address an identified need for oral care.2. Resident 44 did not have a care plan to address enteral feeding (getting nutrition through the stomach) need within 48 hours of admission. These failures resulted in a lack of guidance for staff for the provision of necessary care and placed Resident 44 at risk of inadequate nutrition, infection, decline, and comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services for two of 29 sampled residents (Resident 44 and Resident 152), when:1. Resident 44 did not receive the necessary assistance with oral hygiene in accordance with the residents' assessed needs for seven days. This failure resulted in Resident 44 suffering unnecessary oral discomfort.2. Resident 152 did not receive physical therapy services necessary to maintain or improve functional abilities for two weeks. This failure had the potential to result in decline in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of enteral nutrition (method of delivering liquid nutrition directly into the stomach or small intestine via a tube) for one of 29 sampled residents (Resident 44), when Resident 44 was observed lying flat while receiving nutrition via gastrostomy tube (surgical opening in the stomach to receive nutrients and fluids via a tube). This failure had the potential to result in aspiration (when food, liquid or saliva accidentally go down the airway) and pneumonia (lung infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe handling of oxygen treatment was followed according to facility's policy and procedure to one resident (Resident 61). This failure had the potential to adversely affect Resident 61's respiratory health when her nasal cannula oxygen tubing was not replaced after 7 days of use. During a review of undated admission Record, it indicated Resident 61 was admitted to the facility on [DATE] with diagnosis that included COPD {Chronic Obstructive Pulmonary disease, asthma {a chronic lung condition where airways become inflamed, swollen, and narrow, producing excess mucus, making breathing difficult, dependence on supplemental oxygen. During a concurrent observation and interview on 1/12/2026 at 1:55 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at a palatable and safe temperature to one of 29 sampled residents (Resident 102), when Resident 102 was served cold soup during the meal. This failure had the potential to result in decreased meal satisfaction, inadequate nutritional intake, and increased risk of health complications such as unintended weight loss or dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four outside dumpsters' lids were closed. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 146 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure oversight and monitoring of antibiotic use for one of 29 sampled residents (Resident 44) when Resident 44 was administered two separate antibiotics without documented indication and appropriate physician review. This failure resulted in Resident 44 receiving two unnecessary medications with the possibility of adverse drug reactions and antibiotic resistance. Cross reference to F757Findings:During a review of Resident 44's Face Sheet, Resident 44 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease stage 3, and type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively). During a concurrent interview and record review on 1/16/2026 at 9:18 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was maintained to verify that influenza (a highly contagious viral infection of the respiratory tract) and pneumococcal (a bacterial infection that may cause pneumonia and other serious illnesses) immunizations were offered in accordance with facility policy to one of five residents (Resident 2) reviewed for immunizations. This failure placed Resident 2 at risk for acquiring influenza and/or pneumococcal disease. During a review of Resident 2's face sheet (a document containing demographic information), it was noted that the resident was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy (brain dysfunction caused by a chemical imbalance related to an underlying illness) and Pneumonitis (inflammation of lung tissue) due to aspiration of food and vomit. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow infection prevention and control procedures for COVID-19 (a highly contagious respiratory infection) in accordance with the facility's vaccination policy, when:1. Resident 124 declined the COVID-19 vaccination; however, there was no documentation that the facility provided education regarding the risks and benefits of the vaccine. This failure posed the potential risk of COVID-19 transmission and compromised Resident 124's ability to make an informed decision regarding vaccination. 2. There was no documentation verifying Certified Nursing Assistant (CNA 1) was vaccinated for influenza and COVID-19. This failure risked 146 residents at risk of exposure of influenza and COVID-19.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was served food at a palatable temperature. This failure had the potential for Resident 1 to not eat, lose weight, and not meet his nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Serve residents food timely and at a palatable (pleasant to taste) temperature for two of three sampled residents (Resident 1, Resident 2). 2. Document food temperatures prior to distributing the residents meals for two of three sampled residents (Resident 1, Resident 2). These failures had the potential for reduced resident meal intake and the potential for the residents to contract food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was provided a meal tray for lunch. This failure had the potential for Resident 1 to experience unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent (%) when five medication errors occurred within 39 opportunities resulting in a 12.82% error rate for three of six sampled residents (Resident 45, Resident 74, and Resident 107). This failure had the potential for Resident 45, Resident 74, and Resident 107 not receiving the full therapeutic effects of the medications and potential for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. No Enhanced Barrier Precaution (EBP-infection control strategy that uses Personal Protective Equipment [PPE-equipment worn to minimize exposure to a variety of hazards to reduce the spread of infections]) signage and no PPE supplies outside an EBP room for one of four sampled residents (Resident 18). 2. An opening in the wall between one of three clean and dirty utility rooms present. 3. One of one janitorial cart's trash bin did not have a lid. These failures had the potential to result in the spread of infection to Residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adaptive call light (specially designed call button for individuals with physical disabilities or limited mobility to easily signal for assistance) was provided for one of one sampled dependent resident (Resident 80). This failure resulted in unmet needs due to being unable to call staff.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Personal Property for one of one sampled resident (Resident 13) when Inventory of Personal Effects (IPE) form was not reviewed for accuracy during Resident 13's quarterly care plan conference. This failure resulted in incorrectness of Resident 13's IPE based on her current personal belongings, the inability to verify missing items, and the potential of those missing items not being replaced because they are not on the IPE.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facilities grievance process was followed for one of three sampled residents (Resident 16). This failure had the potential for Resident 16 to be subject to continued abuse and resulted in Resident 16 being unaware of the plan of correction or outcome of the grievance investigation.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse Investigation and Reporting, for one of three sampled residents (Resident 115). This failure had the potential for Resident 115 and the facility's residents to be at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Notice of Transfer/Discharge, when the facility did not send a notice of transfer to the ombudsman (advocate for residents in a long-term care facilities) for two of two sampled residents (Resident 24 and Resident 69). This failure had the potential for Resident 24 and Resident 69 to not have an advocate to review their admission, transfer, and discharge rights and options.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning for two of three sampled residents (Resident 1 and Resident 64) when 1. When a conservator (resident's legal representative) did not participate in Patient 1's care conference. This failure resulted in Resident 1's conservator to not participate in Patient 1's plan of care or be aware of changes in plan of care. 2. When a comprehensive care plan did not include individualized goals and interventions for restorative mobility for Patient 64. This failure had the potential for Patient 64 to not reach full mobility and function potential.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a verbal order (VO) for one of six sampled residents (Resident 116) was entered into the medical record (MR). This failure had the potential for increased risk of medication errors, potential patient harm due to incorrect treatment, and resulted in an incomplete medical record. 2. Follow their policy and procedure (P&P) titled, Medication - Administration for one of six sampled resident (Resident 45) when incorrect dose of medication was given. This failure had the potential for Resident 45 to have adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of one sampled resident (Resident 64): 1. Physician's orders were followed for the Restorative Nursing Assistant (RNA) therapeutic program (program designed to help residents maintain or improve their functional abilities). This failure had the potential to result in decline of Resident 64's strength and mobility. 2. The RNA completed RNA program written weekly summaries. This failure resulted Resident 64's progress towards regaining independence in daily activities was not monitored which had the potential for a decline in function and mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled employees (Supervisor Licensed [SL] 3) had an annual performance evaluation completed. This failure had the potential to result in compromise to the health, safety, and well-being of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed for two of four sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 received smaller portion sizes. This failure had the potential to result in Resident 1 and Resident 2 experiencing weight loss due to receiving smaller portion sizes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food prepared by the facility were prepared in accordance with professional standards for food service safety. This failure had the potential for the facility ' s resident to suffer from food born illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) were treated with respect and dignity. This failure had the potential for Resident 2 to suffer emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to investigate timely and protect one of three sampled residents (Resident 1) when Resident 1 reported missing money and reports of Resident 1 giving money to a staff member (Activity Director). This failure had the potential for Resident 1 to have funds misappropriated.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Fall Management Program, for one of three sampled resident (Resident 2) when the facility failed to: 1. Complete the Post Fall Evaluation (PEE- document to help identify possible causes of a fall and prevent future falls). 2. Develop a care plan (personalized plan of care outlining a person ' s needs and how they will be addressed) to prevent future falls for Resident 2. These failures resulted in Resident 2 falling multiple times in five months and sustaining left intertrochanteric (are bony protrusions on the thighbone) femoral (thigh bone) fracture (broken bone) requiring surgical operation.

Inspectors wroteBased on interview and record review, the facility failed to ensure an injury of unknown origin was reported and investigated for one of three sampled residents (Resident 1). This failure had the potential to negatively affect Resident 1's health and safety.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Fall Management Program, for one of three sampled residents (Resident 1). This failure had the potential for accidents and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Medical Doctor (MD) orders for incentive spirometry (ISP - a breathing exercise that uses a device to help people inhale slowly and deeply to improve lung function) for three of four sampled residents (Resident 1, Resident 2, Resident 3). This failure resulted in MD orders not being followed and had the potential for negative health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document services given for incentive spirometry (ISP - a breathing exercise that uses a device to help people inhale slowly and deeply to improve lung function) for three of four sampled residents (Resident 1, Resident 2, Resident 3). This failure resulted in falsification of documentation and had the potential for adverse health outcomes for Resident 1, Resident 2, and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) on abuse prevention and management when one of five sampled residents (Resident 1) was not assessed for signs of emotional distress after a reported abuse incident. This failure had the potential to result in Resident 1 suffering from psychosocial harm due to lack of assessment for emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to complete an investigation of an abuse incident within five working days for one of five sampled residents (Resident 1). This failure had the potential to put Resident 1 at risk for suffering continual abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of ten sampled residents (Resident 1, Resident 2, and Resident 3) were treated with dignity and their privacy respected, when Resident 1, Resident 2, and Resident 3 were not informed in advance of laboratory (lab) orders. This failure had the potential for Resident 1, Resident 2, and Resident 3 ' s dignity and privacy to be violated and resulted in Resident 1 to suffer humiliation.

Inspectors wroteBased on interview and record review, the facility failed to consistently carry out physicians ' orders for three of three sampled residents (Resident 4, Resident 5, and Resident 6). These failures had the potential for infections to go unnoticed, for treatments to be ineffective, and possible adverse outcomes for Resident 4, Resident 5, and Resident 6.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of three sampled residents (Resident 7) urinary catheter (is a tube placed in the body to drain and collect urine from the bladder) collection bag was not touching the floor. This failure had the potential for Resident 7 to develop a urinary tract infection (UTI start when bacteria get into the tube through which urine leaves the body).

Inspectors wroteBased on interview and record review the facility failed to ensure one of five sampled employees (Director of Nursing [DON]) had the required skills set necessary to ensure residents' safety. This failure had the potential for unqualified staff to supervise the facility ' s residents care.

Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure (P&P) titled, Abuse-Prevention, Screening, & Training Program, when reference checks were not completed for one of five sampled employees (Licensed Vocational Nurse [LVN] 4). This failure had the potential for the facility ' s residents to be exposed to possible abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse Reporting, for one of three sampled residents (Resident 3). This failure resulted in a delay in reporting and had the potential to place all residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication carts were secured and accessible to only licensed nursing staff for one of six sampled medication carts. This failure had the potential for unauthorized staff, residents, and visitors, to gain access to medications which had the potential for adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure (P&P) titled, Medication-Administration, when: 1. Medications were not administered as ordered for one of three sampled residents (Resident 1). 2. Medications were not administered timely for one of three sampled residents (Resident 1). These failures resulted a delay in care and unnecessary nerve pain for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when: A. Medication given via inhalation (the process of breathing in medication) was shared amongst two residents (Resident 1 and Resident 2). B. Certified Nursing Assistant (CNA) 1 did not conduct hand hygiene per facility policy and procedure. These failures had the potential to spread infection to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide psychotropic medications (medications used for mental health disorders) as ordered upon admission by a physician for one of three sampled residents (Resident 1). This resulted in Resident 1 verbalizing decreased ability dealing with stressors (anything that causes worry or emotional difficulty).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide mail to one of three sampled residents (Resident 2) in a manner that would protect his privacy. This failure had the potential for someone to access Resident 2's mail without his consent and potential for violation of residents' rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fluids within reach for one of three sampled residents (Resident 1). This had the potential for Resident 1 to become dehydrated (a condition that occurs when the body loses too much water and other fluids that it needs to work normally).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a call light within reach for one of three sampled residents (Resident 1). This failure had the potential for the resident not to be able to call for assistance and result in negative consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a care plan (CP- provides direction on the type of nursing care the individual may need) for one of three sampled residents (Resident 1) identified as high risk for developing pressure injuries (PI- is localized damage to the skin and underlying soft tissue usually over a bony prominence). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the prescribed nutrition (three meals a day: breakfast, lunch, and dinner) to meet nutritional needs and maintain desirable weight. This failure resulted in a 24.5- pound weight loss and 17.3 percent (%) of body weight in two months for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received the prescribed nutrients. This failure had the potential for unmet care needs and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure titled, Fall Management Program for one of three sampled residents (Resident 1) when Resident 1 did not have quarterly fall risk evaluations completed. This failure had the potential for Resident 1 to have fall incidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Out On Pass [OOP], for one of three sampled residents (Resident 1) when Resident 1's out on pass physician order was incomplete. This failure had the potential for Resident 1 to have negative health outcomes such as an unwitnessed seizure (abnormal electrical activity in the brain that temporarily affects the consciousness, muscle control and behavior), fall, and fracture (broken bone).

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure titled Change of Condition Notification, when the facility did not notify the responsible party of a change of condition for one of three sampled residents (Resident 1). This failure had the potential to result in family not being involved in Resident 1 ' s care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards when one of 22 sampled residents of (Resident 1) was allowed to smoke unsupervised with oxygen applied. This resulted in Resident 1 sustaining second degree burns (partial thickness burns involving the top two layers of the skin) to the right and left cheeks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Seven of 26 sampled residents (Resident 1, Resident 7, Resident 10, Resident 19, Resident 21, Resident 22, and Resident 23) Smoking and Safety (SS) Evaluation identified Resident 1, Resident 7, Resident 10, Resident 19, Resident 21, Resident 22, and Resident 23 ' s ability to hold, light and extinguish a cigarette safely. 2. Ten of 26 sampled residents (Resident 5, Resident 7, Resident 8, Resident 13, Resident 15, Resident 16, Resident 18, Resident 23, Resident 25, and Resident 26) smoking care plans were complete. 3. Four of 26 sampled residents (Resident 5, Resident 16, Resident 23, and Resident 26) SS assessment and care plan for smoking supervision records were accurate. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a care plan meeting in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to delay or impede aspects of care that Resident 1 required and has the potential to affect Resident 1 ' s ability to safely discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) activity assessment were completed. This failure had the potential for Resident 1 and Resident 3's activity needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to re-assess the pain and utilize pain medication according to physician's orders to treat breakthrough pain (a sudden increase in or exacerbation of pain that may occur in residents despite having a stable and well controlled chronic pain regimen) for one of four sampled residents (Resident 1). This failure resulted in unmanaged moderate to severe pain for a terminally ill (illness that cannot be cured and is expected to end in death) resident (Resident 1).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure licensed nurses were competent to administer medications for three of three sampled residents (Resident 1, Resident 2, Resident 3). This failure resulted in licensed nurses not be competent with passing medications and resulted in the wrong amount of medication given to Resident 2 and had the potential to negative effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received services when Licensed Vocational Nurse (LVN) 1 did not administer Resident 2's medications timely. This failure had the potential for adverse effects for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse. This failure had the potential to result in Resident 1 being seriously harmed and affect her psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on theft and loss for one of three sampled residents (Resident 3). This failure resulted in the loss of Resident 3's belongings and had the potential to affect other residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a discharge plan of care according to their policy and procedure for one of four sampled residents (Resident 3). This failure had the potential for harm and/or lack of appropriate services to be provided to Resident 3 upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2) were provided adequate showers or bath. This failure had the potential for Resident 1 and Resident 2's comfort and cleanliness to be affected.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 3) nutritional needs were assessed timely. This failure had the potential for Resident 1 and Resident 3's nutritional needs not to be met.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on controlled medication storage for four of six medication carts. This failure had the potential for residents' inaccurate controlled medication documentation and potential for unidentified controlled medication diversion.

Inspectors wroteBased on interview, and record review, the facility failed to ensure MDS (Minimum Data Set - assessment tool) quarterly (every three months) assessments were completed within 14 days after the ARD [Assessment Reference Date - the specific end point of look-back periods in the MDS assessment process] for one of four sampled residents (Resident 1). This failure had the potential for the delay in assessment and development of Resident 1's individualized care plan.

Inspectors wroteBased on interview, and record review, the facility failed to ensure fall risk evaluation were completed quarterly (every three months) for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential to place Resident 1 and Resident 2 at risk for further falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure on abuse for two of four sample residents (Resident 1 and Resident 2) when: 1. Resident 1 and Resident 2 were not monitored for psychosocial well-being after an altercation incident. 2. The Administrator did not coordinate and implement the facility ' s abuse policy and ensure monitoring, investigation, and documentation of the incident were completed. These failures had the potential to delay the investigation and place Resident 1 and Resident 2 at risk for suffering continuous psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Document notification of the physician and responsible party (RP-resident's decision-maker) of an incident for two of four sample residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 had an altercation incident. 2. Document an assessment of injuries and change of condition for one of four sample residents (Resident 2) after an altercation incident. These failures had the potential to place Resident 1 and Resident 2 at risk for suffering continuous physical or psychosocial harm from the altercation incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the Department an unobserved fall with fracture for one of three sampled residents (Resident 1). This failure resulted in a delay in the investigation of the unwitnessed fall and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was followed for one of three sampled residents (Resident 1). This failure resulted in assessments, monitoring, and notifications not being done after an allegation of abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide suprapubic catheter (a tube inserted through the stomach surgically in order to drain the bladder of urine) care for one of three sampled residents (Resident 1). This failure had the potential for infection to occur and lead to negative consequences up to and including death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was free from verbal abuse. The failure resulted in Resident 1 being verbally abuse by staff.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure titled Unusual Occurrence Reporting when the facility did not report timely within 24 hours when one of three sampled residents (Resident 1) went missing after not returning from an outing. This failure had the potential to place Resident 1 at risk for injuries or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 52 sampled residents' (Resident 13, Resident 90 and Resident 102) call lights were accessible and answered timely when: 1. Resident 13's call light was not within reach. 2. Resident 90's call light was not answered promptly. 3. Resident 102 was not provided a call light that he was able to activate. These failures had the potential for Resident 13, Resident 90 and Resident 102, not being assisted with their activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 13 sampled residents' (Resident 99, Resident 106, and Resident 58) had reasonable access to use a telephone with privacy. This failure resulted in residents not having their rights to privacy while making telephone calls.

Inspectors wroteBased on interview and record review, the facility failed to develop three of four sampled residents' (Resident 3, Resident 20, and Resident 102) individualized activities care plans. These failures had the potential for Resident 3, Resident 20, and Resident 102, not receiving activities specific to their preference or choice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Residents were not assisted with hand hygiene before meals in the dining room. 2. A used syringe (medical instrument for injecting or drawing off liquid) in Resident 84's room was not disposed into a designated container. These failures had the potential to result in spread of infection to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 52 sampled residents' (Resident 235, Resident 131, Resident 236, and Resident 238): 1. Physician's orders were followed for the use of an incentive spirometer (handheld medical device used to help patients improve the functioning of their lungs) for Resident 235, Resident 131, and Resident 236. These failures had the potential to result in respiratory (breathing) complications. 2. Resident 238 was identified before administering medications. This failure had the potential for administering medications to the wrong resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled resident's (Resident 13) was assisted with oral care. This failure resulted in Resident 13 having dental issues and/or tooth decays.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 235) activity assessment was completed. This failure had the potential for Resident 235's activity needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one of one sampled resident (Resident 84) for safe use of cigarette lighters. This failure had the potential to result in accidents and place all residents' safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven sampled residents' (Resident 131 and Resident 239) were free from medication error rate of greater than five percent (%) when two medication errors occurred within 37 opportunities resulting in a 5.41% error rate. This failure had the potential for Resident 131 and Resident 239 not receiving the full therapeutic effects of the medication and potential for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 52 sampled resident's (Resident 106) meal preferences were honored. This had the potential to result in unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of one sampled resident (Resident 104) a therapeutic fortified (added calories) diet according to physician's order. This failure had the potential for not meeting Resident 104's nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Advance Directives (AD - a written instruction such as a living will or durable power of attorney for health care recognized under State law, relating to the provision of future health care decisions) for one of three sampled residents (Resident 1), when facility staff spoke to Resident 1's family member not appointed as a healthcare agent regarding financial transactions. This failure resulted in violating Resident 1's rights for not honoring his legal wishes as indicated in his AD.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy on abuse for one of three sampled residents (Resident 1). This failure had the potential for abuse to continue and for other residents to potentially be abused.