University Park Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to remain free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), when on 6/18/2026 at 8:45AM Resident 2 hit Resident 1 on his (Resident 1) head with an overhead table (an adjustable table designed to roll over a bed and provide a flat and stable surface). This failure resulted in Resident 1 who was bedbound (unable to leave one's bed), feeling scared and being subjected to physical abuse by Resident 2 (who had history of abusing other residents [Resident 3]) while under the care and supervision of the facility on 6/18/2026 at 8:45AM. The facility called 911 (emergency services number) and transferred Resident 1 to a general acute care hospital (GACH). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) titled Abuse Prevention Program with a reviewed date of 1/15/2026 and P&P titled Resident-to-Resident Altercations with a reviewed date of 1/15/2026, for three of three sampled residents (Resident 1, Resident 2, and Resident 3) by failing to: 1. Protect Resident 1 (who was bedbound) from physical abuse on 6/18/2026 at 8:45AM when Resident 2 (who was supposed to be on 72 hours monitoring for verbal aggression and spitting at Resident 3 on 6/15/2026) hit Resident 1 on his (Resident 1) head with an overhead table (an adjustable table designed to roll over a bed and provide a flat and stable surface), and caused a head laceration (a deep cut or tear of the flesh), and bleeding to Resident 1. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to report and investigate an allegation of physical and verbal abuse to the California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and the local police department, within two hours for two of three sampled residents (Resident 2 and Resident 3) by failing to: -Ensure the Director of Nursing (DON), Administrator 1 (ADM1), and Licensed Vocational Nurse 1 (LVN1) reported to the Ombudsman, CDPH, and to the local police on 6/15/2026 at 9:30 AM when Resident 2 (who had a diagnosis of schizophrenia) threatened Resident 3 to beat him up (Resident 3) up, was verbally aggressive, and spit at Resident 3. -Ensure the facility investigated the physical and verbal abuse allegations between Resident 2 and Resident 3 on 6/15/2026. [...]

Inspectors wroteBased on interview and record review, for one of six sampled residents (Resident 1), the facility failed to ensure:Two staff members assisted to transfer Resident 1 from a car onto a wheelchair (WC) on 6/2/2026 at approximately 4 PM to prevent falls. Resident 1's Family Member (FM 1), was trained on how to assist, and safely use and safely transfer Resident 1 in and out of a wheelchair (WC) according to the facility's policy and procedures (P&P) titled Assistive Devices and Equipment dated 1/15/2026. The facility was aware Resident 1 had a history of falls and was at risk accidents and falls. As a result, on 6/2/2026 at approximately 4 PM, Resident 1 slid off the WC and fell to the ground when certified nursing assistant (CNA 1) and FM 1 were transferring Resident 1 from a car onto a WC placing Resident 1 at increased for injury, hospitalization and deathFindings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for four doses of controlled medications (medications with a high risk for abuse or diversion [any use other than that intended by the prescriber]) affecting Resident 18, Resident 29, and Resident 61 in one of two inspected medication carts (Medication Cart 1). This deficient practice increased the risk of diversion (illegal transfer/use) of controlled medications and the risk that Resident 18, Resident 29, and Resident 61 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Five errors out of 27 opportunities contributed to an overall error rate of 18.52 % affecting three of four residents observed for medication administration (Resident 17, Resident 20, and Resident 98). The errors noted were as follows: a. Incorrect drug (senna/docusate - a medication used to stimulate a bowel movement) administered to Resident 98. b. Incorrect drug (senna/docusate) administered to Resident 17.-Failure to administer metformin (a medication used to treat high blood sugar) with food per the physician order for Resident 17. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow the standardized (consistent) recipes for lunch menu on 3/31/2026 by failing to: 1. Ensure 14 residents (unidentified) on pureed diet (foods that do not require chewing and are easily swallowed and should be smooth and pureed to the consistency of pudding) received bread texture in a form that met their needs and in accordance with the international Dysphagia Diet Initiative (IDDSI- a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy, dry, not smooth and had small pieces of bread crust present requiring chewing before swallowing. 2. Follow food production recipes for the renal (related to the kidneys) diet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. One scoop was stored inside bulk rice container, and the handle was in contact with the food. 2. Bulk food (flour, rice, oatmeal) was stored inside trash bags that were not food grade (refers to materials that are safe for direct contact with food, free from harmful substances, and designed to prevent contamination). These deficient practices had the potential to result in cross contamination of food (transfer of harmful bacteria and chemicals from one place to another) that could lead to foodborne illness (food poisoning) in 79 out of 81 residents (unidentified) who received food from the facility.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure one of five sampled residents (Resident 3) was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a patient or in some cases to sedate the patient) by failing to: Ensure Resident 3's physician order dated 4/1/2026 for Haloperidol (Haldol, a type of medication used to treat the symptoms of schizophrenia [a mental illness that affects thoughts, mood, and behavior]) 10 milligrams (mg: unit of measurement) at bedtime specified resident specific behavior manifestations (observable actions, reactions, and physical, visible expressions of an underlying psychological state, emotional condition, or physiological disorder). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to update and revise the tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid) care plan (a plan of care that summarizes a resident's health conditions, current treatments, and specific care and services facility staff (in general) need to provide a resident to promote healing and prevent a worsening of a condition) for one out of one sampled resident (Resident 5) after a new TF order was received on 3/27/2026. This failure had the potential for Resident 5 to receive care that was not in alignment with the resident's needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the Dialysis (process of removing waste products and excess fluid from the body) Communication Record was completed for one of two sampled residents (Resident 1) who received dialysis treatment every Monday, Wednesday, and Friday. This failure had the potential to place Resident 1 at risk for a delay in detecting and treating complications related to dialysis such as infection, bleeding, and hypotension (low blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: Store unopened insulin lispro (a medication used to control blood sugar) in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2.)Store gabapentin solution (a medication used to treat pain) in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 1). The deficient practice of failing to store medications in the refrigerator according to the manufacturer's requirements, increased the risk that residents could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation and interview the facility failed to ensure one of one sampled resident (Resident 1) was made aware of pre-appointment instructions for a Computed Tomography (CT, an imaging procedure used to create detailed images of internal body structures) angiogram (a procedure that uses dye to visualize blood throw through arteries or veins) and cardiac echocardiogram (cardiac echo, an ultrasound test that creates images of the heart's structure) as scheduled on 3/30/2026 at 10 AM as per physician's orders dated 2/18/2026. As a result, Resident 1 could not have the CT angiogram done on 3/30/26, placing the resident at risk for a delay in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call light (a device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach for one of six sampled residents (Resident 68). This deficient practice had the potential to result in staff delay in meeting Resident 68's needs for activities of daily living (ADLS, activities a person performs daily such as bathing, dressing, and toileting), prolonged distress and increased risk of falls for Resident 68.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician timely for one of three sampled residents (Resident 1). The facility failed to notify Resident 1's physician when Resident 1 had been refusing to take Depakote (medication used to treat including mental and mood conditions). This deficient practice had the potential for Resident 1's symptoms of paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) manifested by delusions (having false or unrealistic beliefs) to worsen. During a review of the admission Record indicated the facility admitted Resident 1 on 11/7/24 with diagnoses including paranoid schizophrenia, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and muscle weakness. [...]

Inspectors wroteCross Reference F686Based on interview, and record review, the facility failed to ensure physician orders were implemented on 11/29/2025 and 12/1/2025 for five out of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5), who required daily treatment for wound (a physical injury to the body, like a cut or tear in the skin) management to maintain the highest practicable physical well-being. This failure resulted in lack of daily wound treatment for:a. [...]

Inspectors wroteCross Reference F684 Based on interview, and record review, the facility failed to ensure physician orders were implemented on 11/29/2025 and 12/1/2025 for five out of five sampled residents (Resident 1, Resident 2, Resident 3, and Resident 5), who required daily treatment for wound (a physical injury to the body, like a cut or tear in the skin) management to prevent the development of and or deterioration of pressure injuries (Pressure sore/ulcer-is localized damage to skin and underlying tissues from intense or prolonged pressure, often over bony areas like hips, heels, or tailbone, due to reduced blood flow, exacerbated by friction, shear, and moisture). This failure resulted in lack of daily wound treatment for:a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge summary and plan policy was followed by failing to have the post-discharge plan filled out completely and signed for one of three sampled residents (Resident 1). This failure resulted in Resident 1's post-discharge plan not being completed or signed accordingly. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately assess for wandering behaviors for one of three sampled residents (Resident 1). This failure resulted in inaccurate Minimum Data Set (MDS- resident assessment tool) and had the potential to affect the residents care and services. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Supervise and monitor the whereabouts of one of three sampled residents (Resident 2). Resident 2 had a history of inappropriate sexual behaviors, pulling off his pants, self-pleasuring throughout the day, and rubbing his genitals (genitalia- refers to reproductive organs/private parts) in the presence of residents residing in the facility according to Resident 2's care plan (CP) on (Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch). 2. Protect one of three sampled residents (Resident 1) from sexual abuse (non-consensual sexual contact of any type or sexual harassment) by Resident 2 (Resident 1's roommate). [...]

Inspectors wroteBased on interview and record review the facility failed to report within 2 hours an allegation of resident-to-resident sexual abuse (non-consensual sexual contact of any type or sexual harassment) to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 2). On 10/29/2025 at approximately 7AM-8AM Resident 2 had one hand down his pants and touching himself and with his other hand was trying to touch Resident 1's leg. This failure resulted in a delayed onsite inspection by the CDPH and had the potential for Resident 1 to experience ongoing abuse from Resident 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided to the resident meet professional standard of practice for one of three sampled residents (Resident 1). For Resident 1 the facility failed to ensure the certified nursing assistant (CNA 1) and CNA 1's friend did not ask for money from Resident 1. This deficient practice may potentially expose Resident 1 to financial abuse (willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable room temperature for one of four sampled residents (Resident 1). For Resident 1, the facility failed to ensure Resident 1's room had a room temperature between 71 degrees ( ) Fahrenheit (F, measurement of temperature) to 81 F. Resident 1's room had a room temperature of 84 F on 8/28/25. This deficient practice resulted in Resident 1 stating his room .gets hot and stated he felt uncomfortable. During a review of the admission Record indicated the facility admitted Resident 1 on 6/5/21 and re-admitted on [DATE] with diagnoses including end stage renal disease (kidneys [body organ that remove waste and balance body's fluids] no longer work to meet the body's needs) and depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for two of eight sampled residents (Resident 9 and Resident 42), who was subjected to Resident 392's physical aggression, who had diagnoses of schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior). The facility failed to: -Implement the facility's policy and procedure titled, Abuse Prevention Program, dated 1/16/2025 to protect residents from abuse by anyone including other residents. -Develop a resident specific schizoaffective disorder bipolar type care plan for Resident 392, with interventions to monitor behavior. As a result, on 2/9/2025 at 8:24 pm, Resident 392 hit Resident 42 in the room they shared. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 77), who had diagnoses pneumonia (an infection / inflammation in the lungs that causes inflammation, leads to the accumulation of fluid and pus in the lungs, making it difficult to breathe) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), received necessary care and services in accordance with professional standards of practice by failing to: -Implement the Speech Therapy at Risk for Aspiration care plan interventions dated 1/29/2025, for Resident 77 to receive oral pharyngeal stimulation and exercises (a series of movements designed to strengthen the muscles in the mouth and throat). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide therapy services for two of eight sampled residents (Residents 48 and 6) who had limited range of motion (ROM, full movement potential of a joint [where two bones meet]) by failing to: -Provide Occupational Therapy (OT, rehabilitative profession aimed to increase or maintain a person's capability to participate in everyday life activities) evaluation after identifying a decline in Resident 48's range of motion in the left shoulder, left elbow, left wrist, and left hand during the OT Joint Mobility Screen (JMS, brief assessment of a resident's ROM) dated 8/22/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of 18 sampled residents (Resident 55 and 291) as evidenced by: -Failing to ensure the facility staff changed Resident 55's nasal cannula was changed weekly, the nasal cannula tubing was not on the floor and ensure the facility staff dated and changed Resident 55's oxygen humidifier (a medical device that adds moisture to oxygen to make it more comfortable to breathe) after 24 hours. -Failing to ensure Resident 291's nasal cannula tubing was changed weekly. These deficient practices had the potential for Resident 55 and 291 to experience complications associated with oxygen therapy, such as infection and respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure quetiapine (a medication used to treat mental illness) was used only for conditions or diagnoses as documented in the clinical record in one of five residents sampled for unnecessary medications (Resident 39.) The deficient practice of failing to ensure quetiapine was only used for conditions or diagnoses as documented in the clinical record increased the risk that Resident 39 could have experienced adverse effects related to his psychotropic (medications that affect brain activities associated with mental processes and behavior) medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on interview and record review, the facility failed to initiate the process for a resident representative timely for two of eight sampled residents (Resident 48 and Resident 19) when the facility identified the residents were not able to make medical decisions and did not start the application process for conservatorship until months later. This deficient practice had the potential for the residents to not have a responsible party to assist in making medical decisions based on the resident's best interests and wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 62) participated in care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) meetings to discuss care and discharge goals. This deficient practice had the potential to violate Resident 62's right to be an active participant in their care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of 18 sampled Residents (Resident 51). This deficient practice had the potential to result in Resident 51 not having their needs met and not being able to alert and call facility staff for help during an emergency.

Inspectors wroteBased on interview and record review, the facility failed respect resident rights to self-determination and resident choice by failing to provide one of 18 residents (Resident 9) with his preference for a daily shave. This deficient practice had the potential to affect Resident 9's quality of life and psychosocial well-being (how good you feel about yourself mentally, emotionally, and in your relationships with others)

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the resident's physician (MD 1) for one of eight sampled residents (Resident 48) for a change in condition (COC) for multiple continued refusals during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) by failing to assess, address and report to MD 1 after Restorative Nursing Aide (RNA 3)'s reports of Resident 48's refusals to participate on the RNA Weekly Summary 11/8/24, 11/15/24, 11/22/24, 11/29/24 in accordance with the facility policy and procedure. These deficient practices resulted in the delay in assessment and prevented Resident 48 from receiving alternative interventions and services to improve ROM and prevent worsening left hand contractures (loss of motion of a joint).

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered care plan for one of 18 sampled residents (Resident 60) to meet the resident's needs. The facility failed to develop a care plan for Resident 60's allegation of abuse on 2/10/2025. This deficient practice had the potential lead to the inadequate and delay of the delivery of care of Resident 60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 292) received the necessary care and services to prevent accidents and falls as evidenced by failing to accurately assess Resident 292 when completing fall risk assessments. This deficient practice had the potential to place Resident 292 at an increased risk for recurrent falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the care and services necessary to prevent complications from colostomy (a surgical procedure that creates an opening in the abdomen that allows waste to pass out of the body) for one out of 18 sampled residents (Resident 4) by failing to: -Ensure orders were in place for colostomy care for Resident 4 was readmitted to the facility on [DATE] with a colostomy, there we no orders in place for colostomy care until 2/10/2025. -Ensure staff documented colostomy care given to Resident 4 in the resident's electronic health record (EHR). -Ensure staff dated Resident 4's colostomy bag with the date and time the bag was changed. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform weekly weights and provide a Magic Cup supplement (a frozen dessert that can be served as ice cream or pudding and is used to help residents gain or maintain weight, or to add calories and protein to meals) twice a day with meals for one of 18 sampled residents (Resident 61), who had a history of significant weight loss. This deficient practice had the potential for Resident 61 to experience additional weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide a Restorative Nursing Assistant (a Certified Nursing Assistant who has completed an additional training program that allows them to work with a resident and provide skill practice in such activities as walking and mobility, dressing, and grooming, eating and swallowing, transferring, amputation care, and communication in order to improve and maintain function in physical abilities and activities and prevent further loss of those abilities) Certificate for one of two sampled Restorative Nursing Assistants (Restorative Nursing Assistant 1 [RNA 1]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Six medication errors out of 27 total opportunities contributed to an overall medication error rate of 22.22 % affecting three of four residents observed for medication administration (Residents 5, 34, and 191.) The medication errors noted were as follows: 1. Omitted or late administration of vitamin D (a vitamin supplement) to Resident 191 2. Omitted or late administration of artificial tears (a medication used to treat dry eyes) to Resident 34. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove 36 doses of discontinued divalproex (a medication used to treat seizures) 125 milligrams (mg - a unit of measurement for mass) tablets one of two inspected medication carts (Medication Cart 2.) 2. Store dronabinol (a medication used to increase appetite) 10 mg capsules in the refrigerator per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 1.) The deficient practices of failing to store medications per the manufacturers' requirements and remove discontinued medications from the medication cart increased the risk of residents experiencing adverse effects (dangerous, unwanted side effects of medication) due to improper storage of medication possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed fortified diet (diet to increase caloric intake) guidelines during lunch preparation and tray line observation on 2/10/2025 (a system of food preparation, in which trays move along an assembly line) when: -Fortified diets were not prepared and were not served to residents who were on fortified diets. This deficient practice had the potential to result in meal dissatisfaction, decreased caloric intake and weight loss for seven residents who required a fortified diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: -15 residents on pureed diet received the pureed corn salad in the correct texture (pureed texture is smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep) when the dietary aide prepared and served thin and soupy corn salad instead of pureed corn salad that held its shape and had pudding like consistency. -Two residents on finely chopped diet (modified diet with food prepared approximately 1/8-1/4 inches) and three residents on ground meat diet (hamburger meat consistency) received meat texture in the form that met their needs when [NAME] 1 served flaked fish instead of finely chopped and ground fish per resident diet orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: -Several food items located in the reach in refrigerator were not dated: four turkey and cheese sandwiches, one plate of salad with chopped ham. -One tuna salad sandwich and one turkey and cheese sandwich were stored in the reach in refrigerator with date of 2/7/25 exceeding storage periods for prepared sandwiches. -One bag of deli meat in a plastic bag stored in the reach in freezer with no label or date. Ice crystals were observed in the plastic bag with the deli meat. These deficient practices had the potential to result in harmful bacteria growth that could lead to food borne illness in 83 out of 84 residents and decreased quality of food stored in the freezer due to frost bite and no date.

Inspectors wroteBased on interview and record review, the facility failed to have a policy and procedure for their Bioethics Committee (a multidisciplinary group within a healthcare institution that is consulted when difficult medical decisions need to be made for patients who lack the capacity to make informed choices themselves). This deficient practice placed 13 residents (Residents 84, 48, 27, 25, 3, 20, 28, 41, 12, 11, 86, 19, and 2), who were represented by the facility's Bioethics committee, at risk for ineffective care, needs not being met, and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records for seven sampled residents (Residents 77, 53, 341, 32, 62, 21, and 19) were accurately documented. These seven residents had the exact same vital signs documented by the same Licensed Vocational Nurse (LVN) 4 as the previous shift, on dates 2/8, 2/9, 2/10 and 2/11/2025. This deficient practice caused an increased risk for inadequate care of the residents.

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 three sampled residents (Resident 1), who had a diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought) and mood disorder (a mental health condition that affects a person's emotional state, causing long periods of sadness, depression, mania, or elation). Resident 1 approached and physically became aggressive to Resident 2, while Resident 2 rested in bed and was awaken to see Resident 1 standing over him. As a result, on 11/9/2024, Resident 2 sustained a skin tear on the left ear.

Inspectors wroteBased on interview and record review the facility failed to notify the resident ' s representative when resident was moved from one room to another for one of two sampled residents (Resident 1). For Resident 1 who was moved from Room A to Room B on 10/11/24, the facility failed to inform Resident 1 ' s responsible party (RP) and the reason for the change of rooms before moving Resident 1 on 10/11/24. This deficient practice resulted in Resident 1 and Resident 1 ' s RP not given their right to know and the reason for the move before moving Resident 1 from Room A to Room B.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from neglect (the failure to provide healthcare services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of four sampled residents (Resident 1). On 9/4/2024, Resident 1, who was cognitively impaired (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was left unattended with his body partially uncovered, while lying and crawling on the floor of the facility hallway for approximately 59 minutes. This deficient practice resulted in Resident 1 being subjected to neglect while under the care of the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents that had a fall were assessed by the physical therapist (PT, health professionals that evaluate and take measures to enhance a person ' s physical function for two of two sampled residents (Resident 1 and Resident 2). The facility failed to ensure a PT evaluation was done for Resident 1 after Resident 1 had an unwitnessed fall on 8/12/24. The facility also failed to perform a PT evaluation for Resident 2 when Resident 2 had an unwitnessed fall on 8/14/24. These deficient practices had the potential for the facility not to identify the causative factors of the fall and ensure Resident 1 and Resident 2 were provided with safety awareness and interventions to prevent further falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, may have grandiose delusions [strong beliefs of things that are untrue]) and history of wandering was provided with the necessary behavioral health care as indicated in the comprehensive assessment. The facility failed to: -Monitor Resident 1 for schizophrenic behavior each shift, per the Physician's Order. - Evaluate the care plan interventions for their effectiveness and update or revise the interventions based on resident's behavior and needs. -Develop an appropriate care plan for Resident 1's Wandering, and provide supervision, including the frequency. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a baseline care plan for one of two sampled residents (Resident 1) within 48 hours of resident's admission. Resident 1 did not have a baseline care plan within 48 hours of admission to the facility. This deficient practice had the potential for delayed administration of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to implement the care plan for one of three sampled residents (Resident 1). For Resident 1, who had altered skin integrity in the right antecubital space (part of the arm in front of the elbow) and the bilateral inner thigh, the facility failed to: 1. Assess Resident 1 ' s right antecubital space and bilateral inner thigh every shift as indicated in the comprehensive care plan. 2. Assess Resident 1 ' s skin condition when Resident 1 was re-admitted to the facility on [DATE]. These deficient practices had the potential for the Resident 1 to have infection on the antecubital space, the inner thigh, and the skin graft site.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (intentional bodily injury) for one sampled resident (Resident 1). Resident 1 and Resident 2 were not supervised while in the facility's smoking patio. As a result, on 4/21/2024 Resident 2 picked up a sign and hit Resident 1 in the head with the sign, resulting in Resident 1 having a small abrasion (superficial rub or wearing off the skin, usually caused by a scrape) to the right side of his head.

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 two sampled residents (Resident 1). Resident 2 picked up a folding chair and hit Resident 1 in the head with a chair. This deficient practice resulted in Resident 1 being subjected to physical abuse while under the care of the facility and resulted in Resident 1 having a small laceration (a skin wound) to the left forehead.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized (resident-specific) care plan for one sampled resident (Resident 2) regarding Resident 2's negative behavior. This failure resulted in Resident 2 having an altercation with another resident in the facility after interventions were not in place when Resident 2 had altercations with staff members.

Inspectors wroteBased on interview and record review the facility failed to notify the medical doctor (MD) during a change of condition in blood sugar level (BSL, measurement of glucose [sugar] in the blood using a glucometer) for one of three sampled residents (Resident 1). This deficient practice had potential for the resident not receiving needed treatment for elevated blood sugar, placing the resident at risk for confusion and soma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID -19 (Coronavirus disease 2019, a severe respiratory illness and infectious disease caused by a virus and spread from person to person during close contact and through the air) in accordance with the Center for Disease Control and Prevention (CDC) guideline titled, The Respiratory Protection Information Trusted Source, and the facility's policy titled, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, for five of five sampled residents (Resident 71, Resident 33, Resident 14, Resident 52, and Resident 18 ) out of a total of 82 residents in facility census and four of five staff in the facility by failing to: -Ensure Resident 71, a COVID-19 positive resident, was not in the hallway unmasked. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 66), who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally) and had a history of multiple falls, received the care, treatment and services in accordance with professional standards of practice by failing to: -Provide the correct level of assistance for transfers and ambulation, on 7/19/2023, 8/18/2023 and 9/20/2023, per the comprehensive assessment. -Revise and implement the Fall Care Plan to include different fall interventions needed with specific levels of assistance -Complete / Update a fall risk assessment after each fall As a result of this deficient practice, on 12/8/2023, Resident 66 had an unwitnessed fall, hit the back of her head which required transfer to general acute hospital 2 (GACH 2). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Verification of Informed Consent (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) forms were fully completed for six different psychotropic (medications that affect the mind, emotions, and behavior) medications for two of three sampled residents (Resident 69 and 240). This deficient practice had the potential for the residents to not be fully informed of the risk and benefits of the psychotropic medication they were receiving.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatments and services to minimize decline in joint range of motion (ROM, full movement potential of a joint) for four of seven sampled residents (Residents 37, 43, 54, and 45) who had limited ROM or were assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: -Ensure Resident 37 received quarterly rehabilitation joint mobility screens to monitor changes in joint range of motion; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Director of Nursing (DON) did not act as the Registered Nurse (RN) Supervisor simultaneously (at the same time) for two weeks in December 2023 with a resident cencus above 60 and two weeks in January 2024 with a resident census of 82. This deficient practice caused a decrease the quality of care the residents received.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for the lunch menu were followed on 1/22/2024 when: -Dietary Aide (DA) 3 failed to follow food production recipe for the puree diet dessert (food that is blended to a pudding consistency, no chewing required). Seven residents on regular puree diet received pureed peaches for dessert instead of puree peach upside down cake, per the menu. -Cook 1 served steamed green beans instead of 'Lyonnaise green beans' per the recipe, served turkey breast instead of 'Herb rubbed turkey breast' and added sweet Asian flavor seasoning to the gravy when the recipe did not indicate to add. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare food by methods that conserved flavor, texture, and appearance for 80 out of 82 residents who received food from the kitchen. The texture of the pureed yams was sticky and gummy with glossy and shinny appearance. The color of the pureed yams was light orange, lighter than the yams on regular diet. The pureed green beans were salty and tasted like the chicken base flavor. The pureed turkey was diluted and bland covered with sweet gravy. This deficient practice had the potential to result in meal dissatisfaction, decreased food intake and placed residents at risk for unplanned weight loss.

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: -Personal water bottle and food was stored in the facility two door refrigerator. -One scoop stored inside bulk flour container and the handle in contact with the food. -Floor and shelving in the dry food storage area were dirty. There were food debris on the floors and under the shelves in the dry storage area. There was food debris and crumbs inside storage bins with packets of yellow cake mix. -Used and dirty kitchen wash/wiping cloths were hand washed in the manual dishwashing sink and air dried on the edges of the sink. The sink was used for washing dirty pots and pans, the sink and edges of the sink was not sanitized prior to hanging the towels. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed staff did not falsify the six Facility Verification of Informed Consent (a principle in medical ethics, medical law and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) forms for psychotropic medications (medications that affect the mind, emotions, and behavior) for two of three sampled residents (Resident 69 and 240). This deficient practice had a potential for the residents to receive psychotropic medication without being fully informed of the risk and benefits leading to a decline in the residents' health and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 30) did not keep medication at their bedside without a physician's order and without being assessed to determine if the resident was capable of self-administering medications. These deficient practices had the potential to result in unsafe medication administration or omission.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 18 sampled residents (Resident 30 and 39) had a working call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach. This deficient practice had the potential to result in residents not being able to summon a health care worker for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown cause to the state survey agency (SSA) within 24 hours for one of four sampled residents (Resident 85). This deficient resulted in a delay of an onsite inspection by the Department of Public Health and had potential for an ongoing unknown injuries and resident-to-resident altercation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a person-centered care plan was developed for two of 18 sampled residents (Resident 14 and Resident 39), as evidenced by: -Failing to ensure a care plan was in place for the non-compliance (failing or refusing to comply with a regulation) for Resident 14. -Failing to develop a care plan for dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) for Resident 39. This deficient practice had the potential to result in a failure to deliver necessary care and result in the decline of Resident 14's and Resident 39's health.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled staff (Licensed Vocational Nurse [LVN] 6) had a Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) certificate that was up to date. This deficient practice had the potential for facility residents to receive emergency care that was not up to date leading to resident harm and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain ensure the resdient's the low air loss mattress setting was correct for one of two sampled residents (Resident 70). This deficient practice had the potential to result in the failure of the delivery of necessary care to maintain the skin integrity (the health of skin) of Resident 70.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the oxygen tubing, oxygen mask (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help), and nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) were stored according to infection control practices for one of three sampled residents (Resident 14). This deficient practice had the potential to result in infection control issues and the decline in health for Resident 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications that require refrigeration were stored in the refrigerator according to the manufacturers requirements for two sampled residents (Resident 39 and Resident 17). This deficient practice caused an increased risk in ineffective medications due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review the facility failed to notify a physician(s) that three of three sampled residents (Residents 2, 4 and 5) wanted to leave the facility to leave the facility against medical advice. As a result: 1. Resident 2 whose diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, behaves). Resident 2 had moderate cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), left AMA on 12/29/2023 at 12:30 A.M. 2. Resident 4 whose diagnoses included suicidal ideation (thinking about or planning suicide), left AMA on 7/26/2023 at 9:50 A.M. 3. 3. Resident 5 diagnoses included schizoaffective disorder (a serious mental illness that affects how a person thinks, feels, and/or behaves), left AMA on 7/31/2023 at 11:30 P.M. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedures on abuse (willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish) for two of two sampled residents (Resident 1 and Resident 2). On 12/1/23, Resident 1 and Resident 2 had a verbal altercation. The facility failed to: 1. Provide nursing interventions immediately to Resident 1 and Resident 2 after the altercation on 12/1/23, that would include assessment and monitoring of their psychosocial well-being. 2. Notify immediately the director of nursing (DON) about the altercation between Resident 1 and Resident 2 right after the incident on 12/1/23. [...]

Inspectors wroteBased on interview and record review the facility failed to respect residents rights for one of six sampled residents (Resident 4). On 10/12/2023, Resident 4 was watching television (TV) and Resident 4's roommate complained that the TV volume was too loud. The licensed vocational nurse (LVN 1) went inside Resident 4's room and turned off the TV without asking for Resident 4's permission. This deficient practice resulted in Resident 4 stating that he felt angry, upset, and stated LVN 1 was unprofessional and disrespectful for turning off the TV without asking for his permission.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence that an allegation of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) was thoroughly investigated for one of six sampled residents (Resident 3). On 10/29/2023, Resident 3 alleged that licensed vocational nurse (LVN 1) told Resident 3 that I will tase you . The facility failed to: 1. Include in the facility initial report dated 10/30/2023, the name of the alleged abuser, the potential witnesses and what steps were taken immediately to prevent the alleged abuser from having in contact with Resident 3. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to meet the requirements for the facility-initiated discharge for two of six sampled residents (Resident 1 and Resident 2). The facility issued an Eviction Notice to Resident 1 and Resident 2 on 10/18/23 indicating that Resident 1 and Resident 2 had to vacate the facility and remove all their personal belongings on the 30thday from the date of when the eviction notice was issued. The facility failed to ensure: 1. To implement their Policy and Procedure for Transfer and Discharge. 2. Resident 1 and Resident 2 have a place to go to once discharged from the facility. 3. The location where Resident 1 and Resident 2 will be discharged will be based on Resident 1 and Resident 2's choices and best interest. [...]