The Rehabilitation Center of Los Angeles

Inspectors wroteBased on interview and record review the facility failed to provide clear and concise medical orders for two of three sampled residents (Resident 1 and Resident 3). This deficient practice had the potential to cause confusion among the nursing staff carrying out orders, leading to missed hemodialysis access care, severe infection, and hospitalization. a. During a review of Resident 1's admission Record, the admission Record indicated resident 1 was admitted on [DATE]. With diagnoses including but not limited to displaced intertrochanter fracture of the right femur (a clean break at the top part of the right thigh bone), Bacteremia (bacteria in the bloodstream), and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation for resident needs (the facility's efforts to individualize the resident's physical environment) by failing to: 1. Ensure two of five sampled residents (Resident 1 and Resident 185) had a communication board (a visual tool that uses pictures, symbols, or letters to help people with limited speech express their thoughts) at the bedside as indicated in the facility's Policy and Procedures (P&P) titled Communication Barriers, last reviewed 4/14/2026 and the facility's P&P titled ADL (Activities of Daily Living - activities such as bathing, dressing and toileting a person performs daily) Provided for Dependent Residents, last reviewed 4/14/2026. 2. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure grievances and recommendations voiced through the Resident Council (an independent group of nursing home residents or family, who meet on a regular basis to discuss concerns and suggestions and to plan activities that are important to them) meetings were acted upon and responded to for two out of five residents (Resident 75 and 147) reviewed for resident council concerns who attended a group meeting with the nurse surveyor (Healthcare official that conducts inspections, investigations, surveys and evaluations of health facilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) that meets the needs for three of 33 sampled residents (Resident 4, 169 and 190) by failing to: 1. Ensure a pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) care plan was developed on 5/8/2026 when Resident 4 received a physician's order for Ertapenem Sodium (antibiotic medication) one gram (1 gm) via intravenously (IV-administering fluid medication through a needle or tube inserted into a vein) one time a day for PNA for 10 days.2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) prevention care consistent with professional standards of practice and per physician's orders for three of five sampled residents (Resident 1, 4, and 9) on Low Air Loss Mattresses (LALM, a specialized medical support surface designed to prevent and treat skin breakdown and pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]). By failing to 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 19 pureed diets (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) meal trays received bread texture in the form that met their needs and in accordance with international Dysphagia Diet Initiative IDDSI (IDDSI-a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when on 5/11/2026 kitchen staff served bread that was lumpy, not smooth and had small pieces of bread grains present that required chewing before swallowing on pureed diet trays. This deficient practice had the potential to result in meal dissatisfaction and increased choking risk for the residents on the pureed diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a fortified diet (diet enhanced to increase caloric content of food) for 18 out of 112 meal trays requiring a fortified diet. This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. Three bags of frozen chicken were stored in the reach in freezer with no date or label. One medium container of expired left over chicken tortilla soup with use by date 5/9/2026 was stored in the walk-in refrigerator; Five bags of thawed raw chicken with use by dates of 5/6/2026; Three logs of ground beef with use by date of 5/10/2026 and two large bags of marinated chunks of beef with use by date of 5/8/2026 were stored in the walk in refrigerator exceeding storage periods for raw beef and poultry. 2. Nutrition shakes labeled store frozen with manufactures instruction to use within 14 days of thawing, were not marked with the date they were thawed to ensure expired shakes were discarded after the 14-day time frame. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for two of five sampled residents (Resident 14 and Resident 190), by failing to accurately document on Resident 14's and Resident 190's Dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) Communication Record (a standardized medical document used to safely transfer critical patient information between a dialysis clinic and another care facility). This failure had the potential for nurses (in general) to misinterpret (to understand or explain something incorrectly) the documented information and lead to Resident 14 and Resident 190 receiving inappropriate care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain infection control practices (the set of everyday habits and rules used to stop germs such as viruses and bacteria from spreading) necessary to prevent the spread of infections for four of nine sampled residents (Resident 7, Resident 9, Resident 175, and Resident 186) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 17) who could not self-administer medications did not self-administer Vitamin C (a supplement used to support immune health [body's ability to defend itself against harmful bacteria and viruses], collagen [protein in the body] production, and antioxidant defenses [substances that may prevent or delay some types of cell damage]). This failure had the potential for Resident 17 to self-medicate and result in unsafe medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and respect for one of one sampled resident (Resident 83) when the resident's chest was left exposed with the privacy curtain (a fabric partition used to block the line of sight between beds) pulled open. This failure had the potential to violate Resident 83's right to personal dignity, privacy, and respect, and could negatively affect Resident 83's psychosocial well-being and have impact on Resident 83's self-esteem (sense of personal worth and value).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident 138's privacy curtain was completely closed, and private area was exposed during morning care for one of one sampled resident. This deficient practice had the potential to result in compromised resident dignity, embarrassment, emotional distress, and loss of privacy during care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 186) reviewed for unnecessary medications such as psychotropic (any drug that affects the mental function, behavior, and mood) medications had an end date (expiration date of the physician order) for the use of Ativan (help calm the nervous system) as needed (PRN). This failure had the potential for Resident 186 to become over-medicated, restrict mobility, and experience adverse side effects (unexpected or harmful consequences of medication) such as dizziness and sedation (decrease in awareness).

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman (LTC Ombudsman-an independent, neutral official who investigates and resolves complaints) for one of 10 sampled residents (Resident 3) on 5/11/2026, when Resident 3 was transferred to hospital (GACH) on 5/11/2026. This deficient practice had the potential to prevent the LTC Ombudsman from being informed of Resident 3's facility-initiated transfer and from identifying, monitoring, or addressing potential resident rights concerns related to the transfer.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) for the use of tobacco was accurately completed for one of two sampled residents (Resident 57). This deficient practice had the potential for Resident 57 to receive inadequate and improper care at the facility.

Inspectors wroteBased on interview and record review the facility failed to update and revise the End Stage Renal Disease (ESRD, irreversible kidney disease) and dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care plan (a plan of care that summarizes a resident's health conditions, current treatments, and specific care and services facility staff (in general) need to provide a resident to promote healing and prevent a worsening of a condition) for one out of five sampled residents (Resident 14). By Failing to update Resident 14's care plan on 5/5/2026 when the resident's pick-up time for dialysis was changed. This failure had potential for Resident 14 to miss dialysis and receive care that was not in alignment with the resident's physician orders.

Inspectors wroteBased on interview and record review the facility failed to follow professional standards of practice (the everyday rules and behaviors that keep patients safe and ensure high-quality healthcare) for medication administration (the process of giving medicine to a resident) by failing to ensure subcutaneous (fatty tissue under the skin) injection sites were rotated for two of two sampled residents (Resident 80 and Resident 186):Specifically, the facility failed to:1. Ensure two of two sampled residents (Resident 80 and Resident 186's) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites were rotated (a method to ensure repeated injections are not administered in the same area).2. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide necessary services to maintain good oral care (oral hygiene, the practice of keeping the mouth, teeth, and gums clean and free of disease) for one of one sampled resident (Resident 83) who was dependent on staff for oral hygiene. This failure had potential to affect Resident 83's dignity (providing care that respects a resident's self-esteem, identity, and personal choices) and place the resident at risk for aspiration (accidentally breathing food, liquid, or saliva into the airway and lungs) and tooth decay (damage and destruction of teeth).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent aspiration (when food, liquid, or stomach contents accidentally enter the airway or lungs instead of the stomach) for one of three sampled residents (Resident 17) investigated under the accidents care area by failing to: -Ensure to clarify the route of administration of two Boost (nutritional drinks and shakes designed to provide everyday nutritional support) supplement orders for Resident 17. -Ensure to implement a risk for aspiration care plan (a personalized roadmap that guides how facility staff will manage treatments, medication, therapy goals, and safety precautions for residents) for Resident 17. This failure had the potential to increase Resident 17's risk for aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to maintain gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) care for two of nine sampled residents (Resident 175 and Resident 186) reviewed for tube feeding by failing to: -Ensure the enteral feeding (a way of delivering liquid nutrition directly to your stomach or intestines) tubes for Resident 175 and Resident 186 were capped (covered) and not open to air as indicated by the facility's Policies and Procedures (P&Ps) titled, Infection and Prevention and Control, last reviewed 4/14/2026, and P&P titled Enteral Feeding - Safety Precautions, last reviewed 4/14/2026. This failure placed Resident 175 and Resident 186 at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 14 residents (Resident 80) sampled for respiratory care receive necessary respiratory care and services in accordance with professional standards of practice, by failing to ensure Resident 80's nasal cannula tubing (a device that gives you additional oxygen [an invisible, odorless, and tasteless gas that makes up about 21% of the air we breathe] through your nose) and oxygen humidifier (a water bottled attached to the oxygen machine that adds moisture to oxygen preventing your nose, throat and airways from drying out, cracking, or getting sore) were labeled and dated. This deficient practice had the potential for Resident 80 to experience an increased risk for respiratory infections (illnesses that affect the parts of your body involved in breathing, such as your nose, throat, and lungs).

Inspectors wroteBased on observation, interview and record review, the facility failed to:Implement care plan for hemodialysis (HD, an invasive procedure to filter blood to remove waste and excess water through a machine, to replace kidney function), when a case manager (CM) 2 failed to schedule transportation at prescribed pick-up time for one of one resident (Resident 190). Ensure proper communication was implemented between the facility and hemodialysis center on one of one resident's (Resident 190) hemodialysis treatment and care. Ensure the transportation was not late during hemodialysis appointments for one of one resident (Resident 190). This deficient practices resulted in Resident 190's hemodialysis session shortened, and had a potential to cause fluid retention, shortness of breath, and altered laboratory test results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) for three of five sampled residents (Resident 7, Resident 98, and Resident 151) by failing to: 1. Clarify the physician's order for Resident 7's gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) administration of pantoprazole (a medication used to treat gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back up into the esophagus and causes heartburn) granules (crumbs). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's pharmacy and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) addressed medication irregularities for one of five sampled residents (Resident 7) by failing to: -Ensure the medication administration instructions for Resident 7's pantoprazole (a medication used to treat gastro-esophageal reflux disease [GERD - a condition where stomach acid flows back up into the esophagus and causes heartburn]) granules (crumbs) via gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) were appropriate in accordance with the manufacturer's specifications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 2) sampled for unnecessary medications (a medication that may be doing more harm than good or isn't needed for the resident's current condition) was administered medication in accordance with physician orders and professional standards of practice. By failing to ensure:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for one of five sampled residents (Resident 7) by failing to: -Ensure Resident 7's pantoprazole (a medication used to treat gastro-esophageal reflux disease ([GERD] - a condition where stomach acid flows back up into the esophagus and causes heartburn) delayed-release granules were administered via gastrostomy tube ([g-tube] - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) safely and in accordance with manufacturer's specifications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 2) was free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention). By failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage, labeling and disposal of medications in one of two inspected medication rooms (Station 3 Medication Room) and two of four inspected medication carts (Station 4 Medication Cart 1 and Controlled Care Unit Medication Cart Floor 2) as per manufacturer specifications and facility's policies and procedures (P&P) titled, Medication Storage in the Facility - Storage of Medications, dated 6/2016, Labeling of Biologicals and Storage of Biologicals, dated 1/2026 and Medication Destruction, dated 1/2026, by failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the transportation was not late during hemodialysis appointments for one of one resident (Resident 190). This failure resulted in Resident 190's hemodialysis session shortened, and had a potential to cause fluid retention, shortness of breath, and altered laboratory test results.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance) was within reach for one of four sampled residents (Resident 85). This deficient practice had the potential to result in staff delay in meeting Resident 85's needs for activities of daily living (ADLS, activities a person performs daily such as bathing, dressing, and toileting), prolonged distress and increased risk of falls for Resident 85.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 1 and 2) received care in accordance with the professional standards of practice by failing to answer resident call system in a timely manner. This deficient practice resulted in Resident 1 and Resident 2 feeling neglected, anxious, and helpless. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Vocational Nurse 1 (LVN1) and Certified Nursing Assistant 2 (CNA2) had the competencies necessary to care for two of four sampled residents (Resident 1 and Resident 4) by failing to: 1. Ensure LVN 1, a registry nurse (a staffing agency which provide nursing personnel per shift or temporarily), assigned to Resident 1 had a full skills checklist or performance evaluations in his employee file. 2. Ensure CNA 2, a regular staff member, assigned to Resident 4 had a full skills checklist. This failure had the potential for the employees to have a lack of understanding of their job description and duties and had the potential to neglect (Resident 1 and Resident 4).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received the necessary care and nursing services to prevent recurrent dislodgement of a nephrostomy tube (a tube that is placed directly into the kidney to drain urine from the kidney). This deficient practice resulted in Resident 1 ' s recurrent transfers to General Acute Care Hospital (GACH) on 1/9/2025, 3/23/2025, and 4/6/2025 due to a dislodged nephrostomy tube, requiring repeated invasive procedures (medical procedure where the body is entered or invaded through an incision, percutaneous [through the skin] puncture, or insertion of an instrument). Placing the resident at risk for sepsis (a life-threatening condition that arises when the body's response to an infection damages its own tissues and organs, potentially leading to organ failure and death) and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of nine sampled residents (Resident 64 and Resident 130) were free from physical restraints (any method or device, attached to or near a person's body, that restricts their freedom of movement or access to their body, and which cannot be easily removed) by failing to document the release of the hand mittens (soft, padded mittens used to prevent patients, especially those who are restless, confused, or have cognitive impairments, from pulling out essential lines or tubes), monitoring of skin breakdown (occurs when prolonged pressure on the skin damages the underlying tissues), and monitoring of impaired circulation (a condition where blood flow is reduced or blocked in certain areas of the body) every 2 hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a resident centered comprehensive care plan for two of two sampled resident (Resident 119 and 122), by failing to: -Develop and implement a care plan for Resident 119's rectal tube (a long, thin tube inserted into the rectum [the lower part of the large intestine] to help with issues like relieving gas buildup or managing fecal incontinence, or for administering medications or fluids rectally). -Develop and implement care plans for Resident 122's edema (swelling caused by too much fluid trapped in the body's tissues) and pressure ulcer (damage to the layers of the skin caused by prolonged pressure on a part of the body; Stage 1: red, warm to touch, stays red when pushed down on, Stage 2: break in top layer of skin, stage 3 crater-like appearance damage to top layers and fat layers, Stage 4: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 32 sampled residents received the care and services in accordance with professional standards of practice as evidenced by: -Failing to rotate the insulin administration sites for Resident 49 and Resident 121. -Failing to reassess Resident 127's high blood pressure. These deficient practices had the potential for Resident 49 and 121 to experience lipohypertrophy (a condition where lumps of fat and scar tissue form under the skin, often at insulin injection sites, due to repeated injections in the same area that can impair insulin absorption and lead to inconsistent blood sugar levels and difficulty managing diabetes) and lipodystrophy (a complete or partial loss or abnormal distribution of fat tissue); and for Resident 127 to experience uncontrolled high blood pressure.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure nurses would rotate insulin (synthetic hormone used to control blood sugar level) injection site as per orders, for two of 43 sampled residents (Residents 49, 86), -Failed to ensure there was no discrepancy between the inventory and accountability record of Resident 85's oxycodone (a potent opioid narcotic used to treat pain). -Failed to ensure the Cubex (a computer-controlled system that automates drug dispensing in a health facility) activity record matched the electronic medication administration record (eMAR) for Resident 89's Norco (a combination of hydrocodone and acetaminophen, a potent narcotic to treat pain) administration. These decent practices had the potentials for medication errors, adverse effects, and drug diversion.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure there were specific behavior documentations and consolidated monthly data to track progress or decline (documentation needed to make data-driven treatment decisions and adjustments to interventions) for two of two sampled residents (Residents 7 and 92) who received antipsychotic drugs (a class of drugs used to treat psychotic disorders [mental health conditions characterized by a loss of touch with reality, leading to distorted perceptions, thoughts, and behaviors]). -Failed to place a 14-day limit (a measure to prevent over-prescribing and ensure appropriate use, requiring a physician's re-evaluation and documentation for continued use beyond the 14-days) on an as needed order for Ativan (Lorazepam - a medication used to treat anxiety) for one out of 32 sampled residents (Resident 5). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were regularly trained and evaluated for competency skills when staff were unable to demonstrate correct dishwashing procedures. -Unable to verbalize and demonstrate the correct process of checking quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets and three compartment sink's (sink for dishwashing that have wash, rinse and sanitize compartments) use. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 133 of 206 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of 83 of 206 residents on regular texture diets (diet with no texture restriction) by serving four (4) ounces ([oz], a unit of measurement) instead of three (3) oz. of pork barbecue (BBQ). This deficient practice had the potential to result in excessive nutrients intake of protein, fat, and sodium causing ineffective therapeutic diet provisions, increase blood pressure, increase fat and cholesterol in the diet and unplanned weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food utilizing methods that conserved flavor and appearance when the pureed cabbage did not hold its shape on the plate. -The pork barbecue (BBQ) served for third and fourth station was dry, and the vegetables were olive green in color. This deficient practice placed 91 of 206 (including Resident 127 and 105) facility residents on regular consistency texture (texture with no restriction) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. [NAME] reach-in freezer gasket had dirt buildup and dried up ice cream spill on the bottom shelves. b. Reach-in freezer vents had dirt and dust buildup. c. Vegetable reach-in freezer had dirt and food particles on the bottom shelves. 2. Tuna salad was stored at 43.2 degrees Fahrenheit ([°F], a scale of temperature) and turkey slices were stored at at 48°F, instead of the required 41°F of less. 3. Two dented cans were stored with non-dented cans for the emergency supply canned goods. 4. Kitchen equipment and utensils were not maintained in proper condition, smooth and easy to clean. a. Fifty (50) of 50 resident's trays were cracked. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents food brought in from outside the facility were stored at safe temperature range of 41 degrees Fahrenheit (°F, a scale of temperature) and below. This deficient practice had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 133 of 206 medically compromised residents who store food in the resident's refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when two of four dumpsters (large trash container designed to be emptied into a truck) were not completely closed and covered when not in use, and the surrounding ground was not kept clear of spilled liquids, soiled gloves, and trash. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents was free of significant medication error during medication administration (or med pass) observations (Resident 127). This failure had the potential of adverse effect, and/or worsening of resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure keys that provide access to medication (med) carts would not be left on top of an unattended med cart. This deficient practice had the potential of unsecure drug storage and unauthorized access.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and accident-free environment for one of three sampled residents (Resident 2), who was assessed as high fall risk, impaired gait (walking pattern different than normal) and mobility, and had diagnosis of dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning) by failing to: -Provide Resident 2 supervision to prevent falls, per the facility's policy titled, Fall Management Program. -Develop and implement a person-centered care plan which included supervision to prevent falls and injury. As a result, Resident 2 had a fall on 1/19/2025 at 6:30 AM, in his room, and complained of pain rated at 10 out of 10 (the most severe pain). On 1/19/2025 at 6:03 PM, Resident 2 fell again in his room. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one sampled resident (Resident 1) to return to the facility following a hospitalization on 11/16/2024, 11/24/2024, and 2/3/2025. Resident 1 was transferred to general acute the acute care hospital (GACH) on 8/24/2024. This deficient practice had the potential to result in psychosocial harm for Resident 1, had caused emotional distress and confusion for Resident 1's decision maker family member (FM).

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its ' policy and procedures (P&P) titled Fall Management Program, for one of three sampled residents (Resident 1), who was identified as fall risk and was dependent on staff for orientation and ambulation. This deficient practice resulted in Resident 1 ' s having recurrent unwitnessed falls within 30 days (on 12/17/24; 1/2/2025; and 1/21/2025) in the facility and had the potential for a serious injury or harm to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 4's), assigned staff (certified nurse assistant and licensed vocational nurse) had a background check and license information in their employee file. This deficient practice caused an increased risk in abuse to Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of three sampled residents (Resident 1) by failing to develop a care plan for the antibiotic vancomycin (a strong antibiotic used to treat an infection of the intestines caused by Clostridium difficile, which can cause watery or bloody diarrhea, this medicine may cause some serious side effects, including damage to your hearing and kidneys. These side effects may be more likely to occur in elderly patients). This deficient practice had the potential to result in serious skin reactions, hearing loss, and kidney disfunction.

Inspectors wroteBased on interview and record review the facility failed to administer medication as per physician ' s order for one of two sampled residents (Resident 1). By failing to: 1. Follow physician order to administer Filgrastim (medication that helps the body make more neutrophils [blood cells that helps the body fight infections] 300 micrograms/0.5 milliliter (mcg. /ml., unit of measurement) to Resident 1. The Filgrastim 300 mcg. /0.5 ml was not given to Resident 1 on 6/22/24 at 9 a.m. or on 7/11/24 at 9 a.m. 2. Ensure there was an adequate supply of the Filgrastim 300 mcg. /0.5 ml. readily available for Resident 1. 3. Notify Resident 1 ' s primary physician or oncologist (a doctor who had special training in diagnosing and treating cancer) when the Filgrastim 300 mcg. /0.5 ml. was not available, and Resident 1 missed the doses of Filgrastim on 6/22/24 at 9 a.m. and 7/11/24 at 9 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedure titled Resident Isolation- Categories of Transmission Based Precautions with a review date of 2/21/24 for one of two sampled residents (Resident 1) who was on contact isolation (prevent transmission of infectious agent which are spread by direct or indirect contact with the resident and the resident ' s environment). On 7/16/24 at 9 a.m., certified nursing assistant 1 (CNA 1) did not use a protective gown while taking Resident 1 ' s vital signs (measure the basic function of the body that included temperature and blood pressure). This deficient practice had the potential to spread infection to staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 2) psychotherpeutic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) consent forms were signed by physician prior to administration to the resident. This deficient practice violated the resident's right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents are given their right to privacy for one of two sampled residents (Resident 1). Resident 1 who had an indwelling catheter (a hollow tube left implanted in the bladder [organ that stores urine] to promote urine drainage), the facility failed to provide a privacy cover for the indwelling catheter drainage bag. This deficient practice resulted in failing to provide Resident 1 the right for personal privacy and dignity. During a review of the admission Record indicated the facility admitted Resident 1 on 8/29/18 and readmitted on [DATE] with diagnoses including chronic respiratory failure (not enough oxygen passes in the breathing organs to the blood), obstructive and reflux uropathy (hindrance of normal urine flow) and retention of urine (inability to empty all the urine from the bladder. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the care plan was implemented and the effectiveness of the interventions were reviewed for one of two sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Review the effectiveness of the care plan interventions and revise the care plan each time Resident 1's nephrostomy tube (thin plastic tube that is passed from the back through the skin into the kidney [pair of organs that take away waste matter from the blood] to help drain the urine) was dislodged. 2. Ensure the nephrostomy tube was anchored and secured to prevent from pulling or being dislodged. 3. Ensure nephrostomy drainage bag was kept below Resident 1's bladder. These deficient practices resulted in Resident 1's nephrostomy tube being dislodged on 1/31/24, 2/22/24, 5/7/24, 6/16/24 and 7/3/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the skin of residents from prolonged pressure caused by medical device for one of two sampled residents (Resident 1). For Resident 1, the facility failed to ensure the nephrostomy (thin plastic tube that is passed from the back through the skin into the kidney [pair of organs that take away waste matter from the blood] to help drain the urine) regulator did not cause prolonged pressure to Resident 1's abdomen. On 7/1/24 at 9:16 a.m., Resident 1 was observed with a mark caused by the nephrostomy regulator on right side of her abdomen. This deficient practice had the potential for Resident 1 to develop pressure ulcer related to the medical device.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding reporting of an injury of unknown source in accordance with state or federal law for one of one sampled resident (Resident 1). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injury and accidents were investigated and had potential for an ongoing unknown injury.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to implement infection control policies and procedures (P &P) for four of five sampled residents (residents 1, 3, 4, and 5), by failing to: 1. Identify and prevent the spread of infestation of scabies (i.e., a highly contagious skin condition caused by the itch mite) when Resident 1 had a skin rash on 11/6/2023. 2. Placed Resident 1 on transmission-based precautions (isolation precautions, actions taken to prevent the or control infections) when she was diagnosed to have scabies on 3/27/2024. 3. Implement control measures to prevent the transmission of scabies among residents in the facility, staff, and visitors. 4. Assess Resident 1's roommates (Residents 3, 4, and 5) for potential exposure to scabies. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care, treatment, and services for five of five sampled residents (Residents 1, 2, 3, 4, and 5) in accordance with professional standards of practice in order to meet the residents' physical, mental, and psychosocial needs, by failing to: 1. Conduct proper assessment to identify what was causing generalized and severely itchy skin rashes despite two separate treatments for Resident 1 and generalized dry crusted skin rashes for Resident 5. Resident 1's rash and itching was first identified by the facility on 11/06/2023. 2. Notify a physician that treatment ordered for skin itchy rashes was ineffective according to the resident's care plan. Residents 1, 2, 3, 4, and 5 had no pre-existing skin conditions/rashes upon admission/readmission to the facility. These deficient practices resulted in: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 12 sampled residents (Resident 90 and 96) had the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or Advanced Directives Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice had the potential for Residents 90 and 96 to be denied the right to request or refuse medical care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement resident specific care plans for three of four sampled residents (Resident 9, Resident 31, and Resident 70) by failing to: -Develop and implement a care plan to monitor and provide interventions for Resident 9's weight loss. -Develop and implement a care plan to monitor and provide interventions for Resident 31's urinary tract infection (UTI - an illness in any part of the urinary tract, the system of organs that makes urine). -Implement and administer oxygen therapy (a treatment that provides you with supplemental, or extra, oxygen) as indicated in the care plan for Resident 70. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per physician's orders for three of five sampled residents (Resident 259, 54 and 137) on Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries), by failing to ensure the LALM's were set at the appropriate level. This deficient practice had the potential to delay healing, placed Resident 259, 54 and 137 at risk for developing new pressure injuries, worsening of existing ones, and complications resulting from untreated or improperly treated pressure injuries which could result in systemic infections that could lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate treatment and services outlined in the resident's care plan needed to maintain adequate hydration and nutrition for two of two sampled residents (Residents 109 and 130) receiving enteral nutrition (A form of nutrition that is delivered directly into the digestive system as a liquid) by failing to: -Ensure Resident 109 had an irrigation syringe (a syringe use to flush water into the tubing of a feeding tube [medical device used to provide nutrients and water to the stomach] to prevent clogs) at his bedside. -Ensure Resident 130's water was labeled with the time it was hung as per facility policy and procedures (P&P) titled Enteral Feeding - Safety Precautions last revised on 3/2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 2 and Resident 6) receiving Heparin (anticoagulant: a medication that slows the formation of blood clots) were free from unnecessary medications when the facility failed to ensure Resident 2 and Resident 6's Medical Doctor (MD) ordered prothrombin time (PT- measures the time it takes for the liquid portion of your blood to clot) and international normalized ratio (INR- tells you how long it takes for your blood to clot) monitoring as indicated in the facility's policy and procedures (P&P) titled, Anticoagulant Therapy, dated 3/1/2020. This deficient practice placed Resident 2 and Resident 6 at risk of adverse effects (undesired harmful effects) such as uncontrollable bleeding, organ failure, and death.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure three of 17 sampled residents (Resident 135, Resident 1, and Resident 75), were free from significant medication errors by the administration of medications that may have been stored in unstable refrigerator temperatures in the Subacute refrigerator on Nursing Station 2 between 3/11/2024 to 3/13/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, discard, and/or label medications in accordance with the facility's policy and procedure. The following were observed during inspection of one of five medication carts (MedCart 1) on Nursing Station 3 and one of two medication storage rooms (Subacute Medroom) on Nursing Station 2: 1. One Insulin Glargine Injectable Pen (a long-acting insulin, a hormone that lowers the level of glucose, a type of sugar in the blood) used to treat diabetes (a group of disease that result in too much sugar in the blood) for Resident 117 stored in the MedCart 1 not labeled with an opened date or date when first stored at room temperature. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodations to meet resident needs for one of one sampled resident (Resident 64) by failing to ensure the resident's call light (a device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach of the resident. This deficient practice had the potential to prevent Resident 1 from using the call light to alert staff for assistance, leading to a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change of condition (COC) for one sampled resident (Resident 128) on 2/29/2024 when the resident was found to have a skin tear to the right elbow. This deficient practice placed Resident 128 at risk for a delay in healing, treatment and medical care needed to prevent pain and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's written notice of emergency transfer was provided to the state long-term care Ombudsman (representative appointed by the government who assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) as soon as practicable for one of the six sampled residents (Resident 107), per facility policy and procedures titled Notice of Transfer Discharge dated 3/2023. This deficient practice had the potential to result in the State Long Term Care Ombudsman not being unaware of the resident's status and whereabouts.

Inspectors wroteBased on interview and record review, facility failed to provide one sampled Spanish speaking resident (Resident 126) Spanish translation needed to ensure the resident understood and was able to communicate health care needs, concerns, and plan of care. This deficient practice denied Resident 126 the right to participate in medical decisions, decisions regarding actives of daily living (ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) and actively participate in plan of care.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide necessary services to maintain good health status for one of five sampled residents (Resident 81) dependent on staff for activities of daily living (ADL's: activities related to personal care, bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) by failing to provide one to one (1:1) feeding assistance as per physician's order to Resident 81 during breakfast on 3/12/2024. This failure has the potential for the resident at the facility to experience poor oral intake and be at risk for weight loss and aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 155) identified as at risk for falls was free from accidents by failing to ensure a physician's ordered floor mat (padded mats placed on the floor on either side of the bed to cushion a fall) was placed next to bed for Resident 155. This deficient practice placed Resident 155 at increased risk for falls and complications related to fall injuries such as fractures, cuts, and internal bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one sampled resident (Resident 70) by failing to administer two liters of continuous (without interruption) oxygen therapy (administration of oxygen at concentrations greater than that in the air with the intent of treating or preventing the symptoms of low oxygen) as per physician's order. This deficient practice placed Resident 70 at risk for hypoxia (insufficient amount of oxygen reaching the body's tissues) and respiratory distress (difficulty breathing).

Inspectors wroteBased on interviews and record reviews, the facility failed to keep accurate records for one sampled resident (Resident 209's) pain medication, Percocet (a combination medication used to help relieve moderate to severe pain which contains an opioid pain reliever [oxycodone] and a non-opioid pain reliever [acetaminophen]), by failing to ensure the Controlled Medication (a drug or substance that is controlled by the government because it may be abused or cause addiction) form matched the information on the medication administration record (MAR, a written record of all medications given to a resident). This deficient practice increased the risk of medications may not be administered as prescribed to Resident 209, increasing the risk for medication errors, uncontrolled pain, which could negatively affect the Resident 209's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for one of three sampled residents (Residents 53) observed during medication administration by failing to: -Ensure Resident 53 was administered the entire dose of each medication as ordered and per facility policy and procedures (P&P) titled, Medication Administration-General Guidelines, updated 11/2021. -Ensure facility staff administered medications within 60 minutes of the scheduled time as per facility P&P titled, Medication Administration-General Guidelines, updated 11/2021. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 23's) preferred meal choices were implemented as requested by Resident 23. This failure resulted in a violation of Resident 23's right to have preferred meal choices, with the potential for decreased food intake and inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to: -Store food in accordance with professional standards of practice for food service safety by not labeling 3 boxes of juice with the open date (date indicating packaging opened; used to determine amount of time food can be safely consumed). -Ensure kitchen staff did not use expired quaternary test strips (test strips dipped in sanitizing solution used to detect if the chemical sanitizing solution is the required concentration to meet local health regulations) to check that the quaternary sanitizing solution (ammonium solution used for sanitizing surfaces) was effective. These deficient practices had the potential to cause food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to provide consistent and preferred activities of choice for one of three sampled residents (Resident 5). This failure resulted in Resident 5 feeling angry and had the potential to decrease Resident ' s 5 ' s psychosocial (physical, emotional and/or mental) well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident, (Resident 1) ' s clinical record was updated per facility ' s policy and procedure by failing to: 1. Ensure Resident 1 ' s clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to sufficiently prepare one of one sampled resident (Resident 1) for a safe and orderly discharge from the facility. This deficient practice resulted in Resident 1 ' s requiring transfer to a general acute care hospital (GACH) one hour after discharge from the facility on 1/29/24.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one of one sampled residents (Resident 2) received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) by failing to ensure Resident 2 ' s indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times. This deficient practice had the potential to lead to urine backflowing up into Resident 2 ' s bladder resulting in a UTI, systemin infection, organ failure, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one out of one sampled resident (Resident 2) by failing to ensure Resident 2 ' s nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) were changed weekly as per facility ' s policy and procedure title Oxygen Therapy with a revision date of March 2023. This deficient practice had the potential for the residents to develop respiratory infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four sampled residents (Resident 1, Resident 2) were provided care and services for toenail care to maintain good grooming and personal hygiene. This deficient practice had the potential to result in a negative impact on Resident 1 ' s and Resident 2 ' s quality of life and self-esteem.