The Rehabilitation Center on Pico

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that oral care was provided for one of three sampled residents (Resident 1) who required total assistance with personal hygiene according to care plan. This deficient practice result in that Resident 1 had white debris on his tongue requiring oral cleaning, placing Resident 1 at risk for developing fungal infection (any disease or condition you get from a fungus). During a review of Resident 1's admission records dated 6/10/2026, the admission record indicated Resident 1 was admitted on [DATE] with the diagnoses that included but not limit to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure necessary care and services were provided for one of three sampled residents (Resident 1), who repeatedly refused food, medications, oral care, and hygiene services by failing to:Ensure a white film on the resident's tongue was assessed and treated. Ensure the resident's refusal of food, medications, oral care, and hygiene services were assessed, and care- planned with interventions. Ensure the resident's dentures were properly identified and accessible for use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs for three of three sampled residents (Resident 21, Resident 37, and Resident 50) as evidenced by:Failing to create and implement a care plan for being Out on Pass ([NAME], taking a short, approved, temporary leave from the facility) for Resident 21 and Resident 50. Failing to create and implement a care plan for Resident 37's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). [...]

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 two of three sampled residents (Resident 12 and Resident 37) 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 ensure the LALM's were set at the appropriate level. This failure had the potential for Resident 12 and Resident 37 to develop skin breakdown and/or pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for one of five sampled residents (Resident 81) by failing to ensure Resident 81's bed was not left in a high position. This failure had the potential to increase Resident 81's risk for falls and injury such as broken bones.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in accordance with professional standards to ensure food service safety by failing to: -Discard of expired chlorine (a powerful chemical cleaner/disinfectant used to kill germs) test strips (small, paper-based tools used primarily in commercial settings to measure the concentration of sanitizing chemicals in the final rinse cycle) used to monitor the chlorine chemical level in the facility' s dishwasher. -Discard of expired food items. -Properly labeled food items with a use by date (the last day a product should be consumed). -Label nine of ten drums of water containers. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Interdisciplinary Team (IDT, a collaborative group of healthcare professionals-including nurses, physicians, therapists, social workers, and dietitians-who work together to create and implement personalized care plans) and public patient representative (a trained advocate who acts for long-term care residents lacking decision-making capacity and family, ensuring their wishes or best interests are represented in medical decisions) convened (to come and bring together for a meeting) when one of five sampled residents (Resident 42) did not have the capacity to (the ability to use and understand information to make a decision and communicate any decision made) to provide an informed consent (voluntary agreement to accept treatment after receiving education regarding the risks, benefits, and alternatives to the treatment) [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled residents (Resident 12) was free from physical restraint (any physical, chemical, or mechanical device or method used to limit a patient's movement or restrict their freedom of movement, typically to prevent harm to themselves or others) as evidenced by placing Resident 12's bed against the wall without an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident's Responsible Party (RP, a specific individual or entity legally accountable for making healthcare decisions if the resident is unable to). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) for one of five sampled residents (Resident 81) was accurately completed. This failure had the potential to result in a delay in the necessary care and treatment for Resident 81.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 9) received assistance from the Restorative Nursing Assistants (RNAs) during meals as part of RNA feeding program (a specialized program that focuses on maintaining, improving, and encouraging a resident's functional independence during meals). This failure had potential for Resident 9 to have a decline in meal intake and experience weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 4 (LVN 4) verified medication dosage prior to medication administration for one of seven sampled residents (Resident 31). As a result, Resident 31 received vitamin C (ascorbic acid, a nutrient crucial for immune function and wound healing) at a dose much higher than the dose prescribed. Placing residents at risk for medication errors and negative adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one of five sampled residents (Resident 67) reviewed for infection control by failing to: -Ensure staff (in general) did not store the trash and soiled (dirty) linen carts inside shower room [ROOM NUMBER]. -Ensure staff (in general) cleaned shower room [ROOM NUMBER] after the Social Services Assistant (SSA) removed the trash and soiled linen carts before Certified Nursing Assistant 2 (CNA2) bathed Resident 67 on 3/17/2026 at 9:06 AM. This failure placed Resident 67 at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for one of 38 resident residential rooms (room [ROOM NUMBER]). This failure had the potential to result in inadequate space to provide necessary care, safe nursing care, and privacy for the residents in room [ROOM NUMBER].

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 16 of 38 resident rooms (rooms 101, 102, 103, 104, 110, 111, 112, 113, 214, 215, 216, 217, 219, 220, 221, and 222) met the requirement that each resident must have at least 80 square feet of useable living space in multiple resident rooms. This failure had the potential to result in the inadequate space necessary to provide safe nursing care and privacy for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a Comprehensive Care Plan (CP- a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) for one of three sampled residents (Resident 1), to address Resident 1's Urinary Tract Infection (UTI- infection that happens when bacteria enter the urethra, and infect the urinary tract) after returning from the hospital to the facility. This failure placed Resident 1 at risk for recurrent hospitalizations, which the resident experienced six times from 11/2/2025 through 1/10/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the call light within reach. This failure resulted in Resident 2's inability to call staff for assistance, since she was unable to reach the call light. During a review of Resident 2's admission Record, dated 7/3/25, indicated Resident 2 was admitted to the facility on [DATE], with a diagnoses including; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was provided with the ordered oxygen therapy. This failure resulted in Resident 1 being left without ordered oxygen therapy after personal hygiene care by Certified Nursing Assistant (CNA) and experiencing a temporary desaturation (decrease in the oxygen level of the blood). During a review of Resident 1's admission Record, dated 7/3/25, indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances), HTN and muscle weakness. During a review of Resident 1's History & Physical, dated 12/20/24 indicated the resident does not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were accurately documented and complete for one of three sampled residents (Resident 2). Resident 2 had a history of depression not a current diagnosis of depression, as indicated on Resident 2's face sheet. This deficient practice had the potential to cause errors in medical treatment, plan of care, and delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 11 of 20 sampled residents (Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and 99), were free of significant medication error. The facility failed to: -Ensure Resident 50 was administered Eliquis (apixaban, an anticoagulant, a blood thinner), Norvasc (amlodipine, a medication used to treat high blood pressure), and aspirin for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), in accordance with the physician's orders for eleven days during February 2025. [...]

Inspectors wroteBased on interview, and record review, the facility failed to revise (update) the care plan for 3 sampled residents (Resident 82, 84, and 1) by: -Failing to update the elopement (the act of leaving a facility unsupervised and without prior authorization) / wandering care plan quarterly (every 3 months) as per the facility's policy for Resident 82. -Failing to update the activities care plan quarterly to reflect Resident 84's activity preferences. -Failing to update and revise a Pressure Ulcer (damage to the layers of the skin caused by prolonged pressure on a part of the body) Care Plan to meet the individual needs for Resident 1 with a ischium (a bone in the pelvis that forms the lower and back part of the hip bone) pressure ulcer. This deficient practice had the potential to affect the provision of necessary care, treatment, and services for Resident's 82, 84, and 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Resident 66, 31 and Resident 10) received care and services in accordance with professional standards of practice. Resident 66 did not have the administration site rotated when receiving insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). Resident 31 and Resident 10 did not receive medications in a timely manner. These deficient practices caused an increased risk in the residents reaching their mental, physical and psychosocial needs.

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. Reach in refrigerator vents had dust buildup by the entrance door b. Reach in freezer B bottom shelves had dirt debris c. Reach in freezer shelves had dust buildup. d. Dry storage area shelves had dust buildup. e. Walk-in refrigerator vents had dust buildup. 2. Kitchen equipment and utensils were not maintained in its proper condition, smooth and easy to clean. a. Torn gasket in Freezer A. b. Two racks in the walk-in refrigerator had amber discoloration, rusted, cracked and chipped. c. Ten residents cracked trays. d. Scoop drawer was rusted. 3. Seven (7) dented cans were stored with non-dented cans. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident (Resident 12's) grievance (complaint) about missing items, which included a pair of shorts, a gown, and a brace for his left leg was documented and investigated. This failure led to the resident's grievance being dismissed and had the potential to lead to financial loss, and inability to safely ambulate without the leg brace.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered care plan to meet the resident's needs for one of five sampled residents (Resident 66), as evidenced by failing to create a care plan with goals and interventions for Resident 66's refusal of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). This deficient practice had the potential to lead to inadequate and the delay of care for Resident 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of 25 sampled residents (Resident 42), by failing to ensure Resident 42's oxygen nasal cannula tubing (a device that gives you additional oxygen through your nose) was not resting on the floor while Resident 42 was using the oxygen nasal cannula. This deficient practice had the potential for Resident 42 to experience respiratory infections (infections of parts of the body involved in breathing) associated with using an unsanitary (dirty, unhealthy, or unclean in a way that could endanger health) oxygen nasal cannula tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided for one of 25 sampled residents (Resident 5) that was consistent with professional standards of practice. Resident 5's pain was not reassessed to ensure pain medication was effective. This deficient practice resulted in Resident 5 experiencing uncontrolled pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). There were six medication errors out of 30 total opportunities which contributed to an overall medication error rate of 20 % for one of three sampled residents (Resident 50) observed during medication administration (MedPass). The facility failed to have a medication distribution system to ensure safe administration of medications and ensure Resident 50 was administered medication in accordance with the physician's orders and the facility's policy and procedures titled, Medication Administration - General Guidelines. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff were: -Unable to verbalize the cooling process of food. -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 failures 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 90 of 92 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree yellow zucchini did not hold its shape on the plate and the puree Spanish rice had chunks of rice for residents on puree diet (foods that are smooth with pudding like consistency). These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 9 of 92 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when three of three dumpsters (large trash container designed to be emptied into a truck) were not completely closed or covered when not actively used. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 90 of 92 facility residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of nine sampled facility employees (Licensed Vocational Nurse [LVN] 6 and Restorative Nurse Assistant [RNA] 1) were screened with documented evidence for PPD test (a purified protein derivative [PPD] skin test is a test that determines if you have tuberculosis [TB], a serious infection, usually of the lungs) and clearance as required by the facility's policy and procedure. This deficient practice had the potential to place residents, visitors, and facility staff to tuberculosis exposure by allowing staff to work without proof they were either negative for or did not have symptoms of tuberculosis infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light for one sampled resident (Resident 86). This deficient practice had the potential to result in a delay in meeting Resident 86's needs for hydration, toileting, and activities of daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 17 of 38 resident rooms (rooms 101, 102, 103, 104, 111, 112, 113, 214, 215, 216, 217, 218, 219, 220, 221, 222, and 238) met the requirement of that each resident must have at least 80 square feet of useable living space in multiple resident rooms and at least 100 square feet of useable living space for single rooms. This failure had the potential to affect the delivery of care, safety and wellbeing of the residents.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately assess for pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) risk and pressure ulcer peri-wound (surrounding skin) for one of two sampled residents (Resident 1). This failure resulted in inaccurate identification and documentation of a pressure ulcer for Resident 1 and had the potential to adversely affect the treatment and interventions for the pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1. ensure one of two sampled residents (Resident 1), had measures in place to prevent pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from developing. 2. follow the care plan for pressure ulcer prevention interventions. This resulted in Resident 1 developing an area of non-blanchable redness (possible deep tissue injury, type of pressure ulcer where the injury develops from the bone out to the skin and shows up as a red/purple non-blanchable area [when the skin is pressed but the area pressed does not turn white blood pressed out indicating injury to the underlying tissues]) to their left lateral (away from the middle of the body) heel. Cross-reference with F641.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedures for Intravenous (IV, small tube inserted directly into vein) catheter care to change the IV site within the 72 to 96 hour window for one of four sampled residents (Resident 2). This failure had the potential to result in Resident 2 being exposed to IV site infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents ' (Resident 1) was provided the appropriate oxygen therapy delivery device. On 10/4/24 at 3:45 am Resident 1 was desaturating (decease in blood oxygen levels), and had trouble breathing. This failure resulted in Resident 1 receiving oxygen via a simple mask (oxygen delivery via a mask placed over nose and mouth that can deliver 40 to 60% oxygen at six to 10 liters per minute (L/min) rather than a non-rebreather mask (oxygen delivery via a mask with a one-way valve and reservoir bag that delivers 100% oxygen during an emergency situation).

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1), who had diagnoses of mood affective disorder (a condition that affects a persons emotions) and unspecified psychosis (a condition that makes people lose contact with reality, seeing and hearing things that other people cannot, and believing things that are not true). The facility failed to: -Ensure a complete and adequate comprehensive assessment on 5/29/2024 and 7/24/2024, including cognitive patterns, mood, behaviors, and active diagnoses. -Review and reassess the Mood Impairment care plan interventions quarterly and on a regular basis, per the Abuse Prevention, Agitated or Combative Residents policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care planning for a medical diagnosis psychosis (a mental disorder condition characterized by a disconnection from reality, seeing and hearing things that other people cannot, and believing things that are not true) for one of four sampled residents (Resident 2). This deficient practice had the potential to negatively affect the delivery of provision of care necessary during events of psychotic episodes for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 5 ) when on 4/16/2024 Resident 4 slapped Resident 5 with an open hand. This deficient practice caused Resident 5 pain and redness to the cheek.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility ' s policy and procedures for proper food handling practices was followed by failing to keep a log for the temperatures of the snack cart beverages. This deficient practice had the potential to result in compromised food quality or harmful bacteria growth that could lead to foodborne illness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), had a consult for wound care specialist ordered. This deficeint practice resulted in a delay in the wound care specialist evaluating Resident 1's wounds, placing Resident 1 at risk for worsening wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person centered care plan for one sampled resident (Resident 1). Resident 1 did not have a resident specific care plan for Fall Risk and the care plan was not revised or updated timely. This deficient practice caused an increased risk in falls for Resident 1, who fell on 3/24/2024 with injury.

Inspectors wroteBased on interview, and record review, the facility failed to assure that services being provided meet professional standards of practice for two of three sampled residents (Resident 1 and Resident 2). For Resident 1, the facility failed to: a. Evaluate and analyze hazards and risks for Resident 1 who is had multiple falls. b. Monitor for the effectiveness and modify interventions for a resident who is a non-compliant. As a result, on 3/13/2024, Resident 1 had a fall from his wheelchair when attempted to transfer himself to his bed and was found on the floor. Resident 1 was transferred to GACH 1 via 911 and sustained a right ankle fracture. For Resident 2, who had severely impaired vision, the facility failed to: c. Complete an accurate Fall Risk Assessment on 9/4/2024. d. Evaluate and implement individualized, resident-centered interventions to reduce the risk of fall for Resident 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3), who was a high risk for falls, had a history of multiple falls, and impairment to both lower extremities, received care and services to prevent accidents and falls by failing to: -Revise / update Resident 3's Risk for Falls care plan after the resident had a fall on 8/3/2023 and 9/17/2023. -Implement the Interdisciplinary Team (IDT, group of health care professionals with various areas of expertise who work together toward the goals of their clients) recommendations for Resident 3 to utilize a Geriatric Chair (Geri chair, a large, padded chair with a wheeled base that can recline. The chair is supportive and designed to assist residents with limited mobility and provide more substantial support and comfort than a traditional wheelchair) when up out of bed to prevent falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to store food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness (food poisoning, any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food) as evidenced by: -Failing to dispose of food items past the use by date. -Failing to ensure to store food with a label, open date, and use by date. These deficient practices had the potential to lead to food borne illness for all residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced resident's dignity and respect for one of four sampled residents (Resident 11), by standing over the resident while assisting her during a meal. This deficient practice had the potential to affect Resident 11's sense of self-worth, self-esteem, and psychosocial wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a current copy of the resident's Advance Directive (AD, a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) was in the resident's medical chart for one of four sampled residents (Resident 80). This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment.

Inspectors wroteBased on interview and record review, the facility failed to report a fall with injury to the State Survey Agency (SSA) in a timely manner for one of six sampled residents (Resident 3). This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential for ongoing injuries to Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or implement a care plan for two of six sampled residents (Resident 5 and Resident 30) to address the resident's medical, physical, and psychosocial needs. Resident 5 did not have a communication board which could affect his care., and there was no care plan developed for Resident 30's oral status including missing teeth and chewing deficit. These failures had the potential for Residents 5 and Resident 30 to receive care that was not personalized to meet the specific needs identified above, which could result in decreased quality of care and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for antidepressant medication (used to treat depression, a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily living) when the medication dosage was increased for one of six sampled residents (Resident 69). This deficient practice had the potential to result in Resident 69 receiving inadequate care and services at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 59) received quality of care according to the standards of practice and facility policy, from 10/23/2023 through 11/29/2023 and 12/6/2023 through 2/17/2024, while receiving the medication Sprycel (generic name of Dasatinib, a kinase inhibitors that works by blocking the action of an abnormal protein that signals cancer cells to multiply) for the treatment of leukemia (cancer of the body's blood-forming tissues). This deficient practice resulted in: -Unsafe self-administration of Sprycel by Resident 59 without a Physician's Order and the Interdisciplinary Teams (IDT) approval. -No monitoring of Resident 59's Sprycel treatment for adverse reactions and/or side effects. -The lack of collaboration from the IDT in the treatment of Resident 59's leukemia. Cross Reference:

Inspectors wroteBased on observation, interview and record review, the facility failed to administer two liters of continuous oxygen therapy (administration of oxygen at concentrations greater than that in ambient air) as ordered for one sampled resident (Resident 69). This deficient practice resulted in compromised respiratory care for Resident 69 with a potential for preventable hypoxia (decreased amount of oxygen reaching the body's tissues) with respiratory distress (difficulty breathing).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 59's) total program of care was reviewed, including medications. Resident 59 was taking a luekemia (cancer in the blood) medication for over three months with the Medical Director's knowledge, but without a physician's order or facility staff knowledge. This deficient practice indicated the facility Medical Director and the facility staff did not have an active role in the care of Resident 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer blood pressure (BP) medications safely and as ordered for one of four residents (Resident 41) by not checking the heart rate (HR) as indicated prior to administration. This deficient practice had the potential of preventable complications such as bradycardia (a slow heart rate), dizziness, shortness of breath, fatigue or chest pain for Resident 41, negatively impacting Resident 41's health and well-being.

Inspectors wroteBased on observation, and record review, the facility failed to ensure 17 of 38 resident rooms (Rooms 101, 102, 103, 104, 111, 112, 113, 214, 215, 216, 217, 219, 220, 221, 222, 238, and 218) met the minimum space requirements of 80 square feet for each resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents in Rooms 101, 102, 103, 104, 111, 112, 113, 214, 215, 216, 217, 219, 220, 221, 222, 238 and 218.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled resident (Resident 1) had a right to retain personal possessions by ensuring that all belongings were accounted for in Resident 1 ' s medical record. This deficient practice had the potential to be misplace or lost in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, and functional environment for residents, and staff by failing to ensure maintenance request log was updated as needed per facility policy. This deficient practice had the potential to miss any needed maintenance or delay provision of services to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was free from abuse. CNA student (CS 1) and CS 2 witnessed Certified Nurse Assistant (CNA 1) roughly handling and verbablly demaning towards Resident 1 when providing incontinent (having no or insufficient voluntary control over urination) care. This deficient practice resulted in Resident 1 crying and feeling upset.

Inspectors wroteBased on the interview and record review, the facility failed to ensure one of three samples residents (Resident 1) ' s care plans were followed when Certified Nurse Assistant (CNA 1) roughly handled the resident during incontinent care (having no or insufficient voluntary control over urination). This deficient practice resulted in Resident 1 refusing care, crying and being upset.

Inspectors wroteBased on interview and record review the facility failed to ensure a safe discharge plan for one of three sampled residents (Resident 1) in accordance with the facility ' s policy and procedures titled Transfer and Discharge, dated 10/24/2022, evidenced by not conducting an interdisciplinary (IDT- a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient)team meeting prior to discharge. As a result, Resident 1 was discharged to a lower level of care facility (a facility that provides less services than a skilled nursing facility) who was not able to care for Resident 1 and was admitted to the General Acute Care Hospital (GACH) on the same day.