Trabuco Hills Post Acute

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 4) was assessed for safe self-administration of his medications. * Resident 4 self- administered his testosterone transdermal gel without a prior self-administration of medication evaluation, a physician's order, or a care plan. This failure had the potential for Resident 4 to have a medication administration error.

Inspectors wroteBased on observation, interview , medical record review, and facility P&P review, the facility failed to protect the resident's belongings from theft or loss for one of three sampled residents (Resident 1) who were transferred to the acute care hospital. * The facility failed to ensure Resident 1's belongings were accounted for and properly stored after being transferred to the acute care hospital. This failure resulted in the facility being unable to locate and return the resident's personal belongings after being discharged from the facility.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to follow their P&P after one of four sampled residents (Resident 2) made an allegation she was raped by CNA 1. * The Abuse Coordinator was not timely notified of the abuse allegation. * The facility failed to immediately remove CNA 1 from the resident care areas to protect all the residents from potential abuse. * The facility failed to protect Resident 2 from further abuse and negative outcomes when LVN 1 [NAME] CNA 1 back to Resident 2's room to verify if CNA 1 was the CNA the resident stated raped her. These failures had the potential to put the resident at risk for further abuse and resulted in a delay in the facility initiating their abuse investigation.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for 16 residents who received pureed food. * [NAME] 1 failed followed the recipe when preparing pureed zucchini and yellow squash for the lunch meal on 2/26/26. This failure posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The dish machine sanitizer ppm was less than the required concentration. * Dietary Aide 2 failed to wash his hands and change his gloves between the handling of dirty dishes and clean dishes. * The food preparation equipment was not air dried. * The food preparation equipment was not properly cleaned. * The wall in the kitchen behind the refrigerator was not clean. * Two meal carts were repaired with methods that were not smooth, cleanable surfaces. These failures had the potential to cause foodborne illnesses to the medically vulnerable residents population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for three of three residents (Residents 9, 16, and 22) reviewed for hospice services. * The facility failed to ensure Resident 9's facility plan of care included the frequency of visits by each hospice staff. * The facility failed to ensure Resident 16's medical record contained the visit notes by the hospice aide for February 2026, failed to ensure the hospice visitation calendar showed the scheduled hospice staff visits for February 2026 and failed to ensure the hospice plan of care was incorporated into the facility's care plan to include the frequency of visits for each hospice staff. * The facility failed to ensure future hospice visits were available in Resident 22's medical records. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility failed to ensure the water management program was established and implemented to include the implementation of measures to prevent the growth of Legionella and other opportunistic pathogens; and a way to monitor the measures they had in place. * The facility failed to ensure there were no soiled, stained towels on top of a drawer in the clean linen area and the washing machine had no dust accumulation. * Housekeeping staff's personal water bottle and a cup of vitamins for personal use were stored in the cart with cleaning supplies, paper towels and tissue papers for resident rooms. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the cleanliness and sanitation of the essential equipment for two of two ice machines (Ice Machines A and B). * The facility failed to ensure Ice Machine A was cleaned and sanitized using the recommended solution as per the manufacturer's guidelines. * The facility failed to ensure Ice Machine B was cleaned and sanitized as per the manufacturer's guidelines. In addition, the facility failed to ensure the correct solution ratio was used to clean Ice Machine B as per the cleaning agent instruction for use label. These failures had the potential for the essential equipment to be not cleaned and sanitized properly and could cause food contamination and food-borne illnesses to the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure an effective pest management program was in place. * The facility failed to ensure there were no small flies in the residents dining room. This failure posed the risk of pest contamination during residents mealtimes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 32 final sampled residents (Resident 187) and one nonsampled resident (Resident 162) was assessed, had a care plan and a physician's order to self-administer the medications. * The facility failed to ensure safe self- administration of a medication for Resident 162. * Resident 187's bedside table had an eye drop medications (artificial tears and refresh plus lubricant). There were no self-administration assessment, care plan or physician's order to self-administer the medications and physician's order for the eye drop medications. These failures had the potential for the residents to administer the medications inaccurately and negatively impact the residents' physiological well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of the Advanced Directive for one of six final sampled residents (Resident 107) investigated for Advanced Directives. * Resident 107's Advanced Directive was not in the medical record. This failure had the potential for the resident's wishes related to the provision of medical treatment and services to not be followed if the resident was unable to make medical decisions for themselves.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure resident privacy for one of four final sampled residents (Resident 68) investigated for tube feeding. * Resident 68 was not provided privacy during a GT feeding administration. This failure had the potential for the resident to experience a negative outcome and feel exposed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of 32 final sampled residents (Residents 3, 13, and 16) were free from the unnecessary psychotropic medications. * The facility failed to ensure the nonpharmacological interventions were provided to Resident 3 when Resident 3 had behavior episodes related to the use of quetiapine (antipsychotic medication) and lorazepam (antianxiety medication). * The facility failed to ensure the behaviors were monitored related to the use of quetiapine for Resident 13. In addition, orthostatic blood pressure was not monitored related to the use of the quetiapine medication for Resident 13. * The facility failed to ensure Resident 16's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the quetiapine medication. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 68) investigated for hospitalization was readmitted to their prior room upon return to the facility. * Resident 68 was not readmitted to the same room after returning from the acute care hospital after two days. This failure resulted in the resident being upset having to switch his room once readmitted to the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary transfer/discharge services for one of two final sampled residents (Resident 68) investigated for hospitalization. * Resident 68 was not provided a bed-hold notice when he was discharged from the facility to the acute care hospital on 2/22/26. This failure resulted in the resident being upset having to switch his room once readmitted to the facility.

Inspectors wroteBased on interview and medical record review, and facility P&P review, the facility failed to ensure the PASARR recommendations were followed up and incorporated into the resident care for one of three final sampled residents (Resident 3) reviewed for PASARR. * Resident 3's PASARR - level II determination recommendations were not followed up and incorporated into the resident's care. This failure had the potential for Resident 3 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by an appropriate state-designated authority.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a care plan for two of 32 final sampled residents (Residents 7 and 90). * The facility failed to develop a care plan to address Resident 7's preference to lower his head of the bed during GT feeding. Additionally, there was no care plan developed to address Resident 7's use of hearing devices. * The facility failed to develop a care plan to address Resident 90's weight loss of 11.5% in one month. These failures had the potential for the resident's needs not being communicated to the IDT and placed the resident at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of three final sampled residents (Resident 174) reviewed for accidents. * The facility failed to ensure Resident 174 was accurately assessed for the neurological evaluations after a fall incident on 2/9/26. The facility documented the same vitals signs from the previous neurological evaluations. In addition, the facility failed to ensure Resident 174's blood pressure readings for the sitting, lying, and standing positions were obtained, as per the care plan intervention for Resident 174's fall. These failures had the potential for Resident 174 to not receive the necessary care and services to maintain the resident's highest physical well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident (Resident 7) investigated for hearing received proper assistance with devices to maintain hearing abilities. * Resident 7 had no physician's order for hearing aid use, and the facility did not charge or assist him with his devices. This failure resulted for the resident having difficulty communicating with others.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) for one of four final sampled residents (Resident 9) reviewed for pressure ulcers. * The facility failed to ensure the LAL (Low Air Loss) mattress setting was consistent with Resident 9's weight. Resident 9's current weight was 102 lbs., whereas the LAL mattress setting was set at 150 lbs. This failure posed the risk for Resident 9 to not benefit from the therapy provided by the LAL mattress.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the physician's order was followed for one of three final sampled residents (Resident 107) reviewed for urinary catheter/UTI. * Resident 107 had an indwelling urinary catheter. The facility failed to conduct the voiding trial as per the physician's order for Resident 107. This failure had the potential for the resident to develop indwelling urinary catheter related infection and/or complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of a GT for one of four final sampled residents (Resident 7) and one nonsampled resident (Resident 69) reviewed for tube feedings. * The facility failed to ensure LVN 6 checked for gastric residual prior to flushing the GT. Additionally, LVN 6 failed to administered Resident 69's medications via the GT by gravity. * Resident 7's physician was not notified of the resident's preference to lower their head during GT feed infusion. In addition, the resident's medical record failed to show the facility discussed the risks of lowering their head of bed during tube feeding. These failures posed the risk of Residents 7 and 69 to experience gastric complications and/or discomfort.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper IV care was provided for one of one final sampled resident (Resident 66) receiving an IV fluids. * Resident 66's IV Sodium Chloride 0.45 % (is a sterile, medical-grade mixture of salt and water used primarily as an intravenous (IV) fluid. It is used to hydrate the body, replace fluid loss and electrolytes) bag, IV tubing, and IV site was not labeled and dated. This failure had the potential to place Resident 66 at risk of infection and IV therapy complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one of 32 final sampled residents (Resident 187) and two nonsampled residents (Residents 49 and 54) reviewed for respiratory care. * The facility failed to ensure Resident 187's nasal cannula, nebulizer mask and tubing were stored in a sanitary condition when not in use. *The facility failed to ensure Resident 49's CPAP machine was cleaned and maintained per manufacturers recommendation for cleaning and maintenance. * The facility failed to ensure Resident 54 was not left unattended during administration of albuterol treatment (bronchodilator medication). These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide adequate and appropriate pain management for one of one final sampled resident (Resident 68) investigated for pain. * The facility failed to provide Tramadol (a controlled opioid pain medication) as ordered by the physician for Resident 68. This failure resulted in the resident experiencing pain due to PRN controlled pain medication not being administered.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care and services were provided for one of three final sampled residents (Resident 174) reviewed for dialysis care. * The facility failed to ensure Resident 174's Hemodialysis Communication Records contained accurate documentation for the monitoring of Resident 174's hemodialysis access. * The facility failed to ensure Dialysis Center A was informed of Resident 174's change of condition for an unwitnessed fall on 2/9/26. * The facility failed to ensure the physician was informed of the dialysis center recommendation to hold Resident 174's hypertension medications on the days Resident 174 had hemodialysis treatments and failed to hold the blood pressure medications on the days Resident 174 had the hemodialysis treatments. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services. * The facility failed to ensure eight lidocaine 4% patches were disposed of and destructed properly in one of two medication rooms (Medication room [ROOM NUMBER]). * The facility failed to ensure the narcotic sheets had the nurses' initials and signatures for one of five medication carts (Medication Cart A). * Resident 68's alprazolam (an anxiety medication) was not administered as ordered by the physician. * LVN 7 failed to check the CNA's documentation for Resident 200 who had loose bowel movement prior to administering a stool softener to the resident. These failures had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.67%. Two of five licensed nurses (LVNs 5 and 6) were found to have made errors during the medication administration observation. * LVN 5 failed to administer the complete dose of Resident 46's medication when significant residual of the medication was observed in the medication cup after LVN 5 administered the vitamin B12 (supplement) via GT to Resident 46. * LVN 6 failed to administered the correct medication as ordered by the physician for Resident 69. LVN 6 administered the senna-plus (stimulant laxative with stool softener) medication instead of the sennosides (laxative) as per the physician's order. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services for three of 32 final sampled residents (Residents 13, 22, and 35) and two of five medication carts (Medication Carts A and E) to ensure proper storage and labeling of the medications. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications for one of five Medication Carts (Medication Cart A) inspected. * The facility failed to ensure the orally administered medications were stored separate from the externally used medications for one of five Medication Carts (Medication Cart E) inspected. The suppository Bisacodyl (stimulant laxative) was stored with the oral loperamide (antidiarrheal) and Cepacol oral lozenges. [...]

Inspectors wroteBased on observation, interview, facility document review, and P&P review, the facility failed to ensure one of 16 kitchen staff members (Dietary Aide 2) had the appropriate skill set necessary to safely perform automatic dishwashing. * Dietary Aide 2 was not competent in demonstrating the automatic dishwashing process. This failure had the potential for resident dishes not to be washed correctly which could lead to sanitation concerns.

Inspectors wroteBased on observation, interview, and facility documents review, the facility failed to ensure one of one final sampled residents (Resident 200) reviewed for food accommodations and one nonsampled resident (Resident 164) received food that accommodated the residents' preferences. * Resident 200 did not consistently receive his fruit cup with meals. * Resident 164 was not served the alternative entree for the broccoli. These failures posed the risk of the residents not enjoying their meals and their food preferences not being honored.

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure perishable food brought to the facility from outside sources for resident consumption was allowed to be stored and heated. * The facility failed to ensure the residents were able to store food brought from outside sources in the facility. This failure posed the potential for poor food intake which could lead to weight loss in the 161 residents who consumed an oral diet.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurate medical records for three of 32 final sampled residents (Residents 7, 68, and 198). * Resident 7's admission Social Service Assessment failed to show the resident had hearing devices. * Resident 68's pain monitoring for each shift failed to show the resident's highest level of pain for the shift.* Resident 198's skilled evaluation notes showed the resident was on room air, when the MAR showed the resident was on oxygen. In addition, the resident's MAR had multiple blank entries. These failures resulted in inaccurate and incomplete medical records, and the potential for inaccurate information being communicated to the residents' IDT.

Inspectors wroteBased on interview and facility document review, the facility failed to implement the QAPI plan and the past Recertification Survey POC for F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881. * The facility failed to ensure audits and/or observations for F578 and F803 were completed. Additionally, the facility failed to show the audits and observation findings for F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881 were presented to the QA Committee for review, and continued monitoring. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics for one final sampled resident (Resident 22) and two nonsampled residents (Resident 18 and 95) reviewed for antibiotic stewardship. * The facility failed to ensure the infection screening evaluation was conducted when Resident 18 was prescribed an antibiotic for urinary tract infection. * The facility failed to ensure the infection screening evaluation was conducted when Resident 22 received an antibiotic for upper respiratory infection. * The facility failed to monitor and address the use of the antibiotics on admission when the resident's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for Resident 95. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide education for the influenza and pneumococcal immunizations for two of six final sampled residents (Residents 66 and 195) reviewed for the immunizations. * The facility failed to ensure Resident 66 was offered the influenza and pneumococcal vaccinations. * The facility failed to ensure Resident 195's consent for the pneumococcal vaccination specified the type of pneumococcal vaccine. These failures had the potential for the residents and/or their representatives not being informed of the influenza and pneumococcal vaccines, and the benefits and risks of the vaccines to make an informed decision. In addition, these failures had the potential for the residents to not be aware of the exact type of pneumococcal vaccine being offered by the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were assessed for seasonal COVID-19 vaccination status or offered the COVID-19 vaccine for one of six final sampled residents (Resident 66) reviewed for the COVID-19 vaccination. * The facility failed to determine or offer the COVID-19 vaccine to Resident 66. This failure put the resident at risk for increased risk of infection and transmission of COVID-19.

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' call system was working properly and call buttons were place within the residents' reach for three of 32 sampled residents (Residents 196, 199, and 201). * The facility failed to ensure when Resident 196 would use her call light, the call light was audible and would light up outside Resident 196's room and at the nurses' station panel. * The facility failed to ensure Resident 199's call light button was placed within Resident 199's reach. * The facility failed to ensure Resident 201's call light was working and the silver bell provided to call assistance was placed within Resident 201's reach. These failures posed the risk for the delay in response when the residents would summon the staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility staff was trained on how to document the bowel movements for one of 32 final sampled resident (Resident 200). * The facility failed to ensure CNA 6 knew when to report and how to correctly document the bowel movements in the electronic health record. This failure had the potential for the delay in treatment and/or the resident not to receive the appropriate care.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure an accurate MDS assessment was completed for two of 32 final sampled residents (Residents 198 and 200). * Resident 198's MDS assessment was not coded accurately to show she was administered oxygen while at the facility. * Res 200's MDS assessment was not coded accurately to show the resident's use of a hearing device. These failures posed the risk for the residents to not have an individualized plan of care based on the residents' specific needs.

Inspectors wroteBased on interview and facility assessment review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment included the contracts specifying resources that would assist the facility in case of emergencies, resources needed to care for the residents competently during operations (including nights and weekends), input received from the residents, resident representatives, and family members, a plan to maximize recruitment and retention of the direct care staff and inform contingency planning for events that do not require activation of the facility's emergency plan. This failure posed the risk of the facility not having all needed planned resources in place to care for its residents.

Inspectors wroteBased on observation, interview, closed medical record review and facility P&P review, the facility failed to ensure two of 12 sampled residents (Residents 1 and 2) were free from the unnecessary drugs. * Resident 1 was administered Ativan (antianxiety medication) as needed for inability to relax. The non-pharmacological interventions showed documentation of NA. * Resident 1's Informed Consent form for Cymbalta (antidepressant medication) was not obtained prior to medication administration. * Resident 2 was administered Tramadol (narcotic pain medication) as needed for moderate pain. There was no documentation to show the non-pharmacological interventions were implemented. These failures had the potential for the residents to receive unnecessary drugs with significant side effects.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medical record was safeguarded to protect the confidential health information for one of 12 sampled residents (Resident 4). * Resident 4's Care Log binder containing personal health information was not secured. This failure had the potential for the resident's personal and health information to be accessed from the unauthorized users.

Inspectors wroteBased on interview, closed medical record review and facility P&P review, the facility failed to ensure one of 13 sampled residents (Resident 1) was assessed in a timely manner. * The facility failed to reassess Resident 1's occipital (back of head) when it was deemed unable to visualize upon admission due to matted hair until 3/27/24 (16 days later). This failure had the potential to negatively impact the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure injuries (localized damage to skin and underlying tissue, usually over bony prominences) for one of 12 sampled residents (Resident 11). * The facility failed to ensure Resident 11's low air loss mattress setting was properly set in accordance to the resident's weight. This failure had the potential for Resident 11 to develop pressure injuries or worsening of the existing pressure injuries.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to provide pharmaceutical services to ensure appropriate medication administration for one of 12 sampled residents (Resident 1). * The facility failed to follow the physician's order for the medication administration of a laxative for Resident 1. This failure had the potential to negatively impact the resident.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 12 sampled residents (Resident 1) were complete and accurate. * Resident 1's Neurological Flowsheets and the wound care treatment on 3/24/24, showed blank entries. This failure had the potential for Residents 1's care needs not being met as their medical information was incomplete.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of five sampled residents (Resident 3). * The facility failed to ensure Resident 3's change in condition of aggressive behavior was monitored every shift for 72 hours. In addition, the facility failed to ensure Resident 3's plan of care was revised to address Resident 3's recent behavioral episode. This failure had the potential to negatively affect Resident 3's health and well-being and the potential risk of not providing Resident 3 with appropriate and individualized care.

Inspectors wroteBased on observation, interview, closed medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of five sampled resident (Resident 3). * The facility failed to ensure Resident 3's antianxiety medication was available for administration as ordered by the physician. In addition, the facility failed to ensure the May and June 2025 narcotic count sheets for Resident 3's clonazepam medication were available and kept in the resident's medical record. This failure had the potential to negatively impact the resident's health conditions and psychosocial well-being.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of four sampled residents (Resident 1). * The facility failed to ensure the results of Resident 1's CBC (Complete Blood Count), BMP (Basic Metabolic Panel), and urinalysis test were promptly reported to Resident 1's physician. This failure had the potential for the resident not to receive the necessary care and services to maintain their highest physical well-being and potentially delaying necessary care and treatment.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to notify the resident's representative regarding the resident's change in condition for one of four sampled residents (Resident 1). * The facility failed to notify Resident 1's representative when Resident 1 had poor PO (by mouth, oral) intake (refusing meals/fluids), increased weakness, and confusion, and was sleepy on 8/3/25. This failure had the potential to delay of notification of the resident's changes of condition to the resident's responsible party.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the laboratory tests for one of four sampled residents (Resident 1) was performed as ordered. * The facility failed to ensure Resident 1's physician's order for stat CBC, urinalysis, and BMP laboratory tests were completed in a timely manner. This failure posed the risk for Resident 1 not receiving the appropriate treatment, which could significantly impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure a care plan was developed to address an incident between Janitor 1 and one of six sampled residents (Resident 6). The Maintenance Director and Janitor 1 failed to notify the charge nurse and the DON timely when Resident 6 had a verbal outburst towards Janitor 1 when she was asked to leave the laundry room for safety reasons. This failure placed the resident at risk for not having individualized interventions to address the resident's behavior.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of six sampled residents (Residents 2 and 4) were assessed for safe self-administration of medications. * Resident 2 was observed with a full and uncovered 16 ounces tub of zinc oxide (a medicated cream used as a protective barrier for the affected skin areas) inside his restroom. * Resident 4 was observed with Halls cough drops on the bedside table. These failures had the potential for Residents 2 and 4 to administer the medications inaccurately and may negatively impact the health and safety of the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the rehabilitation services were provided for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1 received the PT and OT services for the planned duration and frequency as documented in the initial PT and OT evaluation. This failure had the potential for Resident 1 to decline in the resident's range of motion and mobility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 sampled residents (Resident 7) was provided rehabilitative services as ordered by the physician. * Resident 7 was not evaluated and treated by the ST four times a week as ordered. This failure had the potential for Resident 7 to aspirate food and fluid into the lungs, which could result in pneumonia.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the personal belongings were safely kept for one of four sampled residents (Resident 2). This failure resulted in the loss of Resident 2's cell phone, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure 19 of 20 final sampled residents (Residents 1, 13, 16, 22, 26, 29, 71, 72, 83, 84, 95, 97, 100, 101, 111, 116, 728, 928, and 931) reviewed for side rail use remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to ensure the accurate and complete assessments and evaluations for the side rails use for Residents 1, 13, 16, 26, 71, 83, 84, 95, 97, 100, 101, 116, 928, and 931. * The facility failed to attempt the alternatives prior to installation of the bed rails for Residents 1, 13, 16, 22, 26, 65, 71, 84, 95, 97, 111, 116, 928, and 931. * The facility failed to obtain the informed consent for the side rails prior to the installation of the grab bars for Residents 83, 101, and 928. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * A bin with multiple pan lids were stored with food crumbs and dirt. * Two blenders, five pink and two brown meal trays were stored wet. * A cutting board with blue colored handle did not have cleanable surface. * A cart with full of dessert in multiple small bowl were unlabeled. * The appropriate hair restraint was not worn by a dietary staff. * The condiments were not stored in sanitary condition. These failures had the potential to result in foodborne illnesses for 134 of 140 residents receiving kitchen services.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P and failed to maintain the infection practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain an accurate infection surveillance program for June, July, August, and September 2024. * Resident 47's urinal was found to be hanging by the trash bin. * LVN 3 wore two pairs of gloves and failed to perform hand hygiene when the top pair of gloves was removed prior to the administration of G-tube medication for Resident 72. * LVN 3 failed to sanitize the stethoscope and blood pressure machine with cuff after using for Resident 931. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to show documented evidence Zone 1 (area of entrapment) measurement was completed for 18 of 20 final sampled residents (Residents 1, 13, 16, 22, 26, 29, 71, 72, 83, 84, 95, 100, 101, 111, 116, 728, 928, and 931) reviewed for side rail use. Also, the facility failed to conduct the monthly entrapment measurements as per the residents' care plans. These failures posed the risk of not ensuring all areas of possible entrapment to be identified.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to assess two nonsampled residents (Residents 113 and 980) for their self-administration of the medications. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for four of 28 final sampled residents (Residents 1, 16, 22, and 97) and one nonsampled resident (Resident 128). * The facility failed to ensure Resident 16's request for an extension cord for the resident's phone was followed up. * The facility failed to ensure the call light was within reach and accessible for Resident 128. * The facility failed to ensure the call light and bed remote control were within the Resident 97's reach. * The facility failed to ensure the call light was within reach for Residents 1 and 22. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to receive care. 1. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure a copy of the advanced directive was obtained for one of 15 final sampled residents (Residents 83) reviewed for advanced directives. This failure had the potential for the resident's decisions regarding his health care and treatments to not be honored.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the residents' physician was notified when the residents refused laboratory collection of blood for two of five final sampled residents (Residents 16 and 95) reviewed for unnecessary medication. This failure had the potential for Residents 16 and 95 not to receive appropriate treatment and could negatively affect residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the personal privacy was maintained for three of 28 final sampled residents (Residents 26, 72, and 931) and the resident's confidential health information on a computer was not protected for one nonsampled resident (Resident 6). * LVN 4 failed to completely close Resident 26's privacy curtain while the GT medications were being administered. Resident 26's abdomen was exposed during the procedure. * LVN 3 failed to completely close Resident 72's privacy curtain while the GT medications were being administered. Resident 72's abdomen was exposed during the procedure. * LVN 6 failed to log off from the electronic medical record where Resident 6's confidential medical information could be seen on the monitor by unauthorized personnel. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman for one of four discharged residents (Resident 125) for closed record reviewed. In addition, the facility failed to provide the notice of transfer/discharge and reasons for the transfer in writing for one of 28 final sampled residents (Resident 25). These failures posed the risk for inappropriate transfers or discharges for Residents 25 and 125 and risk of not providing the residents and their representatives with access to an advocate who could inform them of their options and rights

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of three final sampled residents (Resident 83) reviewed for activities. * The facility failed to provide the activities for Residents 83 to meet the resident's identified preference. This failure had the potential for the residents to experience feelings of social isolation.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure two of four discharged residents (Residents 731 and 828) attained and maintained their highest practicable physical well being when: * The facility failed to provide documented evidence a follow-up call was made to the physician when Resident 828 felt light-headed and had an assisted fall and sustained skin tear on the right lower leg. In addtion, the facility failed to ensure the treatment order obtained from the physician was consistent with Resident 828's injury status post fall. * The facility failed to ensure Resident 731's urine sample was collected in a timely manner and failed to ensure Resident 731's urinalysis result was promptly reported to Resident 731's physician.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of three final sampled residents (Resident 97) reviewed for accident hazards and in the laundry area. * The facility failed to clean and maintain the heating furnace inside the laundry closet. * The facility failed to implement the bilateral floor mats as per the physician's order and plan of care. These failures had the potential for accidents with serious injuries to occur.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary GT care and services for two of two sampled residents (Residents 26 and 72) reviewed for GT care. * The facility failed to ensure the licensed staff assessed for residuals from Resident 26's GT prior to the administration of medication. * The facility failed to ensure the licensed staff verified the placement of Resident 72's GT prior to the administration of medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician's order for oxygen therapy was followed for one of two final sampled residents (Resident 95) reviewed for oxygen administration. This failure had the potential to negatively affect the resident's medical conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled residents (Resident 931) reviewed for dialysis care. * The facility failed to ensure the medications scheduled to be administered to Resident 931 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. In addition, the facility failed to ensure Resident 931's fluid restriction was monitored by the nursing and dietary departments. These failures posed the risk for possible medical complications for Resident 931.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure all controlled medications were accounted for and documented. * The facility failed to ensure the licensed nurses followed the facility's process when opening and dispensing medications from the E-kit (emergency kit). These failures had the potential for drug diversion.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from the drug regimen review were followed through for one of five final sampled residents (Residents 95) reviewed for unnecessary medications. * The Pharmacy Consultant's recommendation for follow up laboratory to recheck the potassium level was not followed through for Resident 95. This failure posed the risk of the resident not receiving the necessary care and services or receiving unnecessary medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 72) reviewed for unnecessary medications was free from the unnecessary psychotropic medications (medications affecting brain activity). * The facility failed to ensure Resident 72 was monitored for the side effects related to the use of bupropion (antidepressant), escitalopram (antidepressant), and trazodone (antidepressant) medications. In addition, the facility failed to ensure the documentation of the monitoring of side effects related to the use of psychotropic medications for Resident 72 in the MAR did not have two different meanings under the chart codes. These failures had the potential to not identify which medication caused the side effects and would negatively impact Resident 72's well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 13.79%. One of three licensed nurses (LVN 1) observed during the medication administration was found to have made errors. * LVN 1 failed to prepare UTI-STAT oral liquid (supplement to reduce the risk of urinary tract infections) and polyethylene glycol 3350 powder (a stool softener to relieve occasional constipation) for one nonsampled resident (Resident 829) as ordered by the physician * LVN 1 failed to assess Resident 829 about her stools or review her medical record for any loose stools prior to the administration of Colace 100 mg (stool softener), as ordered by the physician. * LVN 1 failed to administer hydrocodone-acetaminophen (narcotic pain medication) 10-325 mg to resident 829 as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications and treatment supplies in a safe and secure manner; and failed to ensure the medications were safely stored and accessed by authorized personnel only. * The facility failed to ensure medications were not left unattended. One nonsampled resident (Resident 18's) medications were left unattended on top of the medication cart and on top of her bedside table during a medication administration. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to follow the menu when preparing food for the residents. * The facility failed to ensure [NAME] 1 followed the recipe when preparing puree roast beef and puree potatoes. * The facility failed to ensure the recipe for fruit plate was followed. Resident 131 was served with a plateful of cantaloupe slices and several pieces of grape when the resident requested for a fruit plate. These failures had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications.

Inspectors wroteBased on interview, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure two nonsampled residents (Residents 73 and 110) were accurately and timely reviewed for the appropriate use of antibiotics. This failure had the potential for inappropriate use and increased risk of drug resistant organisms.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure two of two glucometers (Glucometers A and B) were maintained in safe operating condition. In addition, the facility failed to ensure the three residents' refrigerator (in Stations A, B, and C) frozen storage area were free of ice buildup. These failures had the potential for residents requiring blood glucose checks to have inaccurate reading; and the failure had the potential for the food stored in the freezer area were not kept at the proper temperature.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of 28 final sampled residents (Residents 22 and 111) were treated with dignity and respect. This failure posed the risk of the residents' rights not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive person-centered care plan for one of four discharged sampled residents (Resident 828). This failure had the potential to negatively impact the health of the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the assistive devices to help with vision was provided for one of 28 final sampled residents (Resident 47). This failure posed the risk of Resident 47 to not maintain his ability to see and perform his daily activities.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 68) reviewed for urinary tract infection was monitored for the side effects of Bactrim (medication used to treat infections) medication. This failure had the potential to negatively impact Resident 68's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for one of 28 final sampled residents (Resident 69) and one closed record (Resident 731) were complete and accurately documented. * The facility failed to ensure Resident 69's POLST Section D information and signatures were documented. * The facility failed to ensure the AMA form was maintained in the resident's medical records. These failures had the potential for the residents' care needs not being met as their medical information was incomplete and inaccurate

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure one of 28 final sampled residents (Resident 931) had the ceiling suspended curtains to provide privacy. This failure had the potential to negatively affect the resident's dignity, privacy, and self-esteem.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician and RP were notified of the skin changes for one of two sampled residents (Resident 1). This failure posed the risk of Resident 1 to experience a delay in receiving care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of two sampled residents (Resident 1). * Resident 1 had the OT recommendations for the built-up utensils from January 2024 through April 2024. However, this recommendation was not addressed throughout the resident's therapy sessions. This failure had the potential to negatively affect the resident's health condition and well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was correctly administered her blood pressure medication. This failure posed the risk of Resident 1 not receiving the appropriate treatment as ordered.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 2) was provided the opportunity to participate in the care plan conferences. This failure had the potential for Resident 2 to not be able to choose treatment options and make decisions in care planning.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to accurately document the history of falls on the Fall Risk Assessment form status post an unwitnessed fall for one of five sampled residents (Resident 1). This failure posed the risk for changes in Resident 1's health condition not being identified and accurately assessed.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer or provide a nourishing snack to one of three sampled residents (Resident 1). This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure proper covering, labeling, and dating of foods in the kitchen. * The facility failed to ensure proper thawing of frozen food from the freezer. * The facility failed to ensure the sanitizing solution in dishwasher was checked before use. * The facility failed to ensure the Dietary Aide was wearing a hair net. * The facility failed to ensure the blender was cleaned and sanitized after use. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to accommodate the needs for one of 24 final sampled residents (Resident 232). * The facility failed to ensure Resident 232 was provided with bilateral bed grab bars to enable repositioning and bed mobility as ordered by the physician. This failure had led to Resident 232 feeling helpless, upset, and uncomfortable, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives for two of 20 final sampled residents (Residents 62 and 75). This had the potential for the facility to provide treatment and services against the residents' wishes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to implement the plan of care to reflect the individual care needs for one of 24 final sampled residents (Resident 580). * Resident 580's plan of care included the use of floor mats by Resident 580's bedside due to frequent falls; however, the facility failed to implement a fall intervention to address Resident 580 as care planned. This failure posed the risk of not providing the appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the supervision during meals for one of 20 final sampled residents (Resident 3) to prevent him from choking. * The facility failed to ensure Resident 3 was provided 1:1 close supervision during meals as ordered by the physician. This failure had the potential for the resident to aspirate food particles and a potential delay in staff intervention.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 20 final sampled residents (Resident 73) who was on oxygen therapy. * The facility failed to follow the physician's order for Resident 73's oxygen therapy. This failure posed the risk for the resident to develop complications related to oxygen use.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the medications and biologicals were properly stored and secured. * Medication Cart 1 was left unlocked and unsecured in the hallway. This failure had to the,potential for unauthorized personnel, residents, and/or visitors having access to the medications. * Two liquid medication bottles which had medication residues on the outside were found to bestored with other clean liquid medication bottles. This had the potential for medication contamination. *IV Cart 1 had a dollar bill stored with the IV supplies. In addition, the expired IV supply and sterile products were found to be outside of the original sterile packaging were observed stored in IV Cart 1. This posed the risk for the residents to be potentially exposed to the expired and contaminated medical supplies.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the safe and sanitary storage of food brought from home for one nonsampled resident (Resident 231). This failure had the potential for the resident to be exposed to food borne illnesses.

Inspectors wroteBased on observation and interview, the facility failed to ensure the infection control practices were maintained in the facility's laundry room area. * Laundry Staff 1 was observed eating next to a pile of clean linen. * Trash were observed under the table used for clean linen. These failures had the potential for the contamination of linen used by medically vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide a safe and homelike environment for one nonsampled resident (Resident 12). * A hole with visible pipes approximately 4.5 inches wide and 6 inches in height was observed on the dry wall below Resident 12's bathroom sink. In addition, the beige walls of Resident's 12's room (Room A) was patched with a white material in nine different places and not repainted. These failures had the potential to negatively impact the quality of life and increased risk for physical discomfort for Resident 12.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the menu was followed for one nonsampled resident (Resident 69). * Resident 69 was served with plain spaghetti noodles when the lunch menu showed Italian meat sauce with spaghetti noodles. This failure had the potential for Resident 69's nutritional needs not being met which could further compromise their medical status.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food preferences were followed for one of 20 final sampled residents (Residents 46). * The facility failed to ensure Resident 46's food preference was followed. This failure had the potential to result in meal dissatisfaction which could lead to decreased meal intake which could lead to a compromised nutritional and medical status.

Inspectors wroteBased on observation and interview, the facility failed to transport, store, and dispose of trash in a safe and sanitary manner. * The recycle dumpster was overfilled with cardboard and used pizza boxes which prevented the lid from closing. This failure had the potential to attract vermin (rats, mice and insects) and promote the spread of germs in the facility, potentially resulting in the spread of disease and foodborne illnesses.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure complete and accurate medical records for three of 20 final sampled residents (Residents 3, 32 and 75). * The facility failed to show documentation of Resident 3's indwelling catheter care. *The facility failed to show documentation of Resident 32's Restorative Nurse Aide (RNA) services. * Resident 23's advance directive was not in the current medical record. These failures resulted in inaccurate documentation of care provided and resident status and preferences.