Valley Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to:Follow their policy and procedure (P&P) titled, WanderGaurd [sic](device used as safety protocol used to assist staff in monitoring people at risk for wandering near exits) Policy and Procedure for one of three sampled residents (Resident 1) when Respiratory Therapist (RT) responded to Resident 1's wanderguard alarm but did not check outside the surrounding area to ensure Resident 1 did not exit the facility premises. Ensure the every 30-minute monitoring log were completed for one of three sampled residents (Resident 1) with a history of elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for two of three sampled residents with high risk for elopement (Resident 2 and Resident 3) when the south hallway alarm was not activated. This failure had the potential for Resident 2 and Resident 3 to elope. During an observation and interview on 7/6/25 at 1:54 p.m. with Licensed Vocational Nurse (LVN) in the facility's south hallway, the exit alarm did not alarmed when door was opened. LVN stated the exit alarm can only be turned off by a key and should be on at all times. During an interview on 7/6/26 at 2:40 p.m. with Administrator (Admin), Admin stated the exit door alarms should not be turned off. During an interview on 7/14/26 at 1:53 p.m. with Central Supply (CS), CS stated she disarms the exit alarm when she goes outside. CS stated she disarmed it on 7/6/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders (PO) were followed for one of three sampled Residents (Resident 2) when Resident 2's Wanderguard band (system designed to help alert staff when residents wearing Wanderguard band are trying to exit facility) was used against manufactures instructions for proper usage. This failure had the potential for Resident 2 to leave the facility without staff being aware. During an observation on 7/6/26 at 2:14 p.m. in Resident 2's room. Resident 2 had the wanderguard wristband on her right ankle. During a review of Resident 2's PO, dated 11/4/25, the PO indicated, MONITOR PLACEMENT OF WANDEGURARD (RIGHT WRIST) QSHIFT (every shift). During a concurrent interview and record reviewed on 7/14/26 at 2:08 p.m. with Director of Nursing (DON), the Wanderguard Manufacture Instructions (WMI) were reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess, develop, and implement interventions as well as implement the facility's policy and procedures (P&P) for one of 22 Residents (Resident 3) when: Resident 3 had nine falls with injuries between admission date (9/5/25) to hospitalization (12/1/25). These failures resulted in Resident 3 having two hospitalizations (11/3/25 & 12/1/25) with multiple injuries including skin tears, a fracture (broken bone) in the neck of left femur (top part of leg bone is broken), which required surgical intervention, and need for rehabilitation (action of restoring someone to health or normal life through training and therapy after illness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call system was available and functional for the residents in two of two sampled shower rooms. This failure had the potential to put the residents at risk for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary and homelike environment for nine out of 22 residents (Resident 2, Resident 17, Resident 21, Resident 45, Resident 54, Resident 55, Resident 63, Resident 65, and Resident 72). This failure had the potential to increase risk for falls, effect resident dignity, and result in low self-esteem.

Inspectors wroteBased on interview and record review the facility failed to have Certified Nursing Assistant (CNA)'s who have successfully completed either a nurse aide training or a competency evaluation program (is a structured and regulated process that measures an individual's knowledge, skills, and behaviors against establish job requirement) for three of three CNA's (CNA 1, CNA 2, and CNA 3). This failure resulted in CNA 1, CNA 2, and CNA 3 not be evaluated to determine if they were competent to provide resident care services.

Inspectors wroteBased on interview and record review, the facility failed to:Follow their policy and procedure (P&P) titled Drug Disposition when two controlled medications were not accounted for on the facility's medication disposition form (document used to record the secure destruction or disposal of expired, discontinued or unwanted medication). This failure had the potential for abuse of controlled (highly, abusive) medication. Authenticate the medication for one of one sampled resident (Resident 56). This failure had the potential for Resident 56 to receive an unknown medication and not being monitored for side effects.

Inspectors wroteBased on interview and record review the facility failed to implement their policy and procedure (P&P) titled DISHWASHING, when a facility dishwasher failed to reach the mandatory temperature to sanitize resident dishware and/or failed to document the temperature the dishwasher was reaching to ensure sanitation. This failure had the potential for a foodborne illness outbreak to occur resulting in harm up to and including death.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on Change of Condition Notification, for one of three sampled residents (Resident 53). This failure resulted in Resident 53 having unmet care needs for high blood pressure (force of blood pushing when your heart beat) and heart rate (the number of times when the hear beats per minute) which could result in damage to the heart, kidneys, brain, and result in heart attack.

Inspectors wroteBased on interview and record review the facility failed to have clear clinical justification to provide Zyprexa (a medication used to treat psychosis [mental state where you lose touch with reality, experiencing things that aren't real or hold strong false beliefs]) to one of 22 residents (Resident 82). This failure had the potential cause medication induced harm.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting, for one of 22 sampled residents (Resident 3) when the facility did not report to the California Department of Public Health (CDPH) Resident 3's fall with injury (fracture [broken bone] of left leg) with subsequent hospitalization, need for surgical intervention, and rehabilitation. This failure resulted in the facility not reporting to CDPH and resulted in a lack of investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for three of 22 sampled residents (Resident 9, Resident 56, and Resident 64): Resident 64's use of mind altering substances (Marijuana) substance while driving vehicle. This failure had the potential to put Resident 64, other residents, staff, and visitors at risk for accidents. 2. Resident 9's continued behavior of non-compliance. This failure had the potential for unmet care needs. 3. Resident 56 was on anti-viral medication. This failure had the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) on:1. Out on Pass for one of three sampled residents (Resident 64) when Resident 64 was going out on pass without a physician order, and Resident 64 was not assessed by a licensed nurse prior to leaving out on pass and after coming back to the facility. These failures had the potential to jeopardize Resident 64's safety and had the potential for Resident 64 to receive delay in care. 2. Wound Management for one of two sampled residents (Resident 35) when Resident 35's gastrostomy tube (GT - small, soft tube placed through the skin directly into the stomach to deliver food, liquids, and medicine) site was not being treated as ordered by the physician and there was no care plan developed to manage Resident 35's skin irritation around the GT site. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the individualized activities services for one of 22 sampled residents (Resident 97). This failure had the potential for Resident 97 to have diminished functional needs to promote maximum participation in activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to give one of 22 sampled residents (Resident 35) oxygen per the physicians' orders. This failure had the potential for hypoxia (insufficient oxygen reaching body tissues to maintain normal function causing shortness of breath, confusion, rapid heart rate, bluish skin, and other negative outcomes up to and including death).

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 22 sampled residents (Resident 98, Resident 97, and Resident 35) had staff with skills (specific abilities to perform their job) and competency (knowledge, skills, abilities, and behaviors) to provide care and services when: 1. Registered Nurses (RN 1, RN 2, RN 3, RN 4, RN 5, and Director of Nursing [DON]) were not competent to provide TPN (total parenteral nutrition - is a method of delivering all essential nutrients-such as protein, carbohydrates, fats, vitamins, and minerals-directly into the bloodstream through an PICC ( a long, this, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) line for two of two sampled residents (Resident 98 and Resident 97). This failure had the potential for TPN associated negative outcomes up to and including death. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored at proper temperature. This failure had the potential for medication to be ineffective or harmful to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the correct amount of ingredients to a meal per the facility recipe for three of 22 residents (Resident 21, Resident 51, Resident 80). This failure had the potential for Resident 21, Resident 51, and Resident 80's nutritional and caloric intake to be inaccurate and result in unwanted weight loss or gain.

Inspectors wroteBased on observation, interview, and record review the facility failed to:Label and date opened food items. Maintain a clean refrigerator per policy and procedure (P&P) REFRIGERATOR AND FREEZER. Accurately document the temperature of the facility dry food storage area. These failures had the potential to cause food to spoil and cause foodborne illness.

Inspectors wroteBased on interview and record review facility failed to follow its policy and procedure (P&P) titled, Infection Prevention and Control Program, when there was no surveillance conducted on nursing staff. This failure had the potential for unsanitary conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure 23 of 34 resident rooms measured at least 80 square feet per resident. This failure had the potential for residents to experience negative outcomes due to having insufficient personal space in their rooms.

Inspectors wroteBased on interview and record review, the facility failed to report results of investigation of the allegation of abuse to the California Department of Public Health (CDPH) within five days of the incident for two of two sampled residents (Resident 1 and Resident 2). This failure had the potential to delay the investigation of the abuse allegation incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4,and Resident 5). This failure had the potential to cause resident harm, decrease resident comfort, and affect resident dignity. During an observation on 7/2/25 at 1:31 p.m. in Resident 1's room, the following was observed in the shared resident restroom/shower room (Resident 1's restroom is also used by the facility to provide showers for the other residents): a. On the ceiling directly over the sink was an oval shaped approximately 12-inch (a unit of measurement) area of multiple orange and black shaped dots scattered around. b. On the ceiling toward the shower stall entry was approximately 24-inch in length by 24-inch in width area of exposed wood with three exposed screws.c. [...]

Inspectors wroteBased on interview and record review, the facility failed to address the hydration (the process of replenishing the water content in the body) needs of one of three sampled residents (Resident 1) who was dependent on hydration and nutrition via gastrostomy tube (G-Tube is a tube inserted through the belly that brings nutrition and hydration directly to the stomach), and who had an order for nothing by mouth (NPO) when there was no physician's order for hydration/water flushes, the physician was not notified of the Registered Dietician's (RD) recommendations for hydration, RD did not follow up timely to ensure the recommendations for hydration was carried out, and the facility did not follow their policy and procedure (P&P) on Intake and Output Recording to monitor and record intake and output of residents with feeding tube. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan (a detailed document outlining how the facility staff will provide care to meet the resident's specific needs) interventions as recommended by the Interdisciplinary Team (IDT - a group of healthcare professionals who collaborate to provide comprehensive care to a patient) for one of three sampled residents (Resident 1). [...]

Inspectors wroteBased on interview and record review the facility Quality Assurance and Performance Improvement (QAPI-systematic process for ensuring that products and services ensure quality care) committee failed to maintain, identify, and correct a physical environment deficient practice identified by the survey team (reference tag F-919). This failure resulted in a non-functional resident restroom call light system and an unsafe physical environment of care for all 85 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 18 of 18 resident bathrooms and three of three resident shower rooms had operational call lights within reach of residents. This failure had the potential for all 85 residents not to be able to call for help if they required assistance while using the bathrooms and shower rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Med Pass for two of three sampled medication carts (Medication Cart 1 and Medication Cart 2). This failure had the potential for residents, staff, and visitors to unsafely access medications.

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to ensure three of three dietary staff (DS 1, DS 2 and DS 3) washed their hands according to the Centers for Disease Control and Prevention (CDC) guidelines on hand washing and failed to ensure its policy and procedure (P&P) on Hand Hygiene conformed to the CDC guidelines on hand washing. This failure had the potential for the spread of infectious diseases in the facility. 2. Failed to ensure it kept an inventory of Personal Protective Equipment (PPE - gowns, gloves, masks, goggles and faceshields). This failure had the potential for the facility to run out of PPE and placing residents at risk of infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure 23 of 34 resident rooms measured at least 80 square feet per resident in multiple resident rooms. This failure had the potential for residents to experience negative outcomes due to having insufficient personal space in their rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Responsible Party (RP) 1 was notified when a change in diet texture was ordered for one of four sampled residents (Resident 35). This failure resulted in RP 1 not being aware of changes in Resident 35's status.

Inspectors wroteBased on interview and record review the facility failed to ensure resident assessments were completed for two of two sampled dialysis (medical procedure that filters waste products and excess fluids from the blood when the kidneys no longer function adequately) residents (Resident 8 and Resident 59). This failure resulted in an incomplete assessment of Resident 8 after dialysis, and an incomplete assessment of Resident 59 before and after dialysis.

Inspectors wroteBased on interview and record review that facility failed to ensure one of five sampled residents (Resident 13) psychotropic medication (medication that alters mood, behavior, and mentation), Oxcarbazepine (medication prescribed for bipolar-mood disorder) was reviewed quarterly (every 3 months) by the interdisciplinary team (IDT- healthcare professionals including physician, pharmacist, social services, activities, and nursing). This failure resulted in Resident 13 not having an IDT medication review for Oxcarbazepine and had the potential for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its food preparation sink in the kitchen had an air gap (a backflow prevention device consisting of vertical space between the water outlet and flood level of a sink designed to ensure contaminated water does not flow back into the clean water supply). This failure had the potential to contaminate residents' food supply and exposure to infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed and implemented for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to experience accidents and injuries.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, when two of three sampled residents (Resident 1 and Resident 3) medical doctor (MD) was not notified regarding the allegation of abuse and one of three sampled residents (Resident 1) responsible party (RP) was not notified of the allegation of abuse. These failures had the potential for Resident 1 and Resident 3 ' s MD and Resident 1 ' s RP not to be aware of Resident 1 and Resident 3 ' s allegation of abuse.

Inspectors wroteBased on interview and record review, the facility failed to consistently implement care plans for two of three sampled residents (Resident 1 and Resident 3). This failure had the potential for Resident 1 and Resident 3 to have unmet psychosocial and physical needs.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable access to a telephone that provided privacy for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in a violation of residents' rights to a private conversation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer (or injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) Prevention for one of three sampled residents (Resident 1) when: 1. Resident 1 was not assessed for risk for developing pressure injuries upon admission. 2. Physician was not notified to obtain treatment for Resident 1's left heel redness. 3. A care plan (resident centered health document designed to facilitate communication among members of the care team with the resident) was not developed to address Resident 1's left heel redness. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) medical records were accurate. This failure resulted in inaccurate information in Resident 1's medical record.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Discharge Against Medical Advice, on contacting Adult Protective Services (APS - a program that promotes the safety, independence, and quality-of-life for vulnerable adults) when one of three sampled residents (Resident 1) left the facility against medical advice (AMA - leaving a facility prior to a doctor recommends discharge). This had the potential for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the air mattress (a pressure-relief device that is constantly being inflated with air to prevent skin breakdown, wounds and/or assist with the healing of wounds) for three of three sampled residents (Resident 1, Resident 2 and Resident 3) was in safe operating condition. This failure had the potential to impact the safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen per physician's orders for one of three sampled residents (Resident 1). This failure had the potential for negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurses (LVN) 2 and LVN 4 performed skin assessment through direct observations, licensed nurses developed a care plan for the condition of the feet, licensed nurses notified the attending physician regarding the condition of the feet, Certified Nursing Assistant (CNA) 2 reported to the licensed nurses the condition of the feet, CNAs documented their observations of the condition of the feet using the facility's Comprehensive Certified Nursing Assistant Shower Review Form (CCNASRF), and the podiatrist provided appropriate medical foot care and treatment for two of two sampled residents (Resident 15 and Resident 36). This failure resulted in pain, discomfort, and neglect (state of not receiving enough care or attention) of Resident 15 and Resident 36's skin and foot care.

Inspectors wroteBased on interview and record review, the facility failed to ensure activity assessments were completed for 16 of 16 sampled residents (Resident 6, Resident 9, Resident 12, Resident 27, Resident 60, Resident 82, Resident 135, Resident 185, Resident 200, Resident 201, Resident 202, Resident 203, Resident 204, Resident 205, Resident 206, Resident 207). This failure had the potential for residents to not meet their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff competencies for five of five sampled Licensed Nursing Staff (Registered Nurse [RN] 1, RN 2, RN 3, Licensed Vocational Nurse [LVN] 4, and LVN 6) were evaluated and completed. This failure had the potential to result in harm to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the kitchen was maintained in a sanitary manner for 71 of 71 sampled residents. 2. Ensure food was properly stored and labeled for 71 and 71 sampled residents. 3. Ensure employees followed dress code policy for two of two sampled staff (Dietary Supervisor (DS) and [NAME] 2 (CK) 2). 4. Ensure food was served in a sanitary manner for one of one sampled resident (Resident 61). These failures had the potential for the spread of foodborne illnesses throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure infection control practices were implemented for 4 of 4 sampled residents (Resident 27, Resident 5, Resident 48, and Resident 15) in accordance with nationally recognized infection control and prevention guidelines. This failure had the potential to transmit infectious diseases. 2. Ensure staff implemented infection control practices for handling trash, transmission-based precautions, and laundry services for 71 of 71 residents residing in the facility. This failure had the potential to transmit infectious diseases or parasite infestations throughout the facility. 3. Conduct infection prevention surveillance activities (collection and analysis of data) on hand hygiene effectively. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Control Preventionist (IP-health professional responsible for preventing and controlling the spread of infections) maintained Influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and Pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi) vaccinations for all current residents in the facility. This failure had the potential for the residents to not have the immunity for certain infectious diseases, which could be detrimental to their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP-health professional responsible for preventing and controlling the spread of infections) maintained an accurate record of the Employee COVID-19 (a highly contagious respiratory illness caused by coronavirus) Vaccination for 110 of 159 employees. This failure resulted in incomplete employee COVID-19 vaccination record and unaccounted number of employees with or without immunity to the type of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure five of five Licensed Nurses (Registered Nurse [RN] 1, RN 2, RN 3, Licensed Vocational Nurse [LVN] 4, and LVN 6) were trained to meet the behavioral health requirements of 29 of 29 sampled residents (Resident 1, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 17, Resident 21, Resident 27, Resident 28, Resident 30, Resident 31, Resident 36, Resident 37, Resident 43, Resident 44, Resident 46, Resident 48, Resident 53, Resident 55, Resident 56, Resident 60, Resident 61, Resident 71, Resident 76, Resident 135, Resident 185, Resident 202, and Resident 204). This failure had the potential to result in staff being unable to provide appropriate assessments and interventions for residents with behavioral health needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Resident 43, Resident 52, and Resident 3) had Minimum Data Set (MDS- resident assessment tool) assessments completed timely. This failure had the potential to result in unidentified health problems.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Pharmacy Consultant conducted Medication Regimen Review (MRR- a thorough evaluation of the residents' medications and minimizing adverse consequences) for two of two sampled residents (Resident 15 and Resident 55) on psychotropic (refer to antidepressants, anti-anxiety, stimulants, antipsychotic, and mood stabilizers) medications. 2. Ensure Pharmacy Consultant conducted monthly medication review for all 71 residents in the facility . These failures had the potential for adverse consequences when there is no pharmacy oversight and monitoring of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a language-assistance service for one of one sampled resident (Resident 64). This failure had the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 15 and Resident 26) had access to a call light. This failure had the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Notification of Responsible Party, when the responsible party was not notified of a change of condition for one of four sampled residents (Resident 17). This failure had the potential to result in family not being involved in Resident 17's care.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate transfer/discharge documents signed by the Responsible Party for one of one sampled resident (Resident 55) with dementia (group of symptoms affecting memory, thinking and social abilities). This failure had the potential to result in an unsafe and unorderly transfer for Resident 55 without the family being aware.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of four sampled residents (Resident 15, Resident 19, Resident 56, and Resident 209) received a summary of the Baseline Care Plan (BCP-the minimum healthcare information necessary to properly care for each resident immediately upon their admission) within 48 hours of admission. This failure had the potential for unmet care needs for Resident 15, Resident 19, Resident 56, and Resident 209.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan for two of two sampled residents (Resident 208 and Resident 55). This failure had the potential for negative outcomes.

Inspectors wroteBased on interview and record review the facility failed to administer medication according to the physician's order for one of three sampled residents (Resident 209). This failure had the potential for adverse outcomes for Resident 209.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Notify a Medical Doctor (MD) of a change in one of three sampled residents (Resident 208) condition. 2. Conduct an Interdisciplinary team (IDT - a group of various professionals that coordinate assessment and treatment for residents, so that problems can be dealt with consistently and comprehensively) for one of three sampled residents' (Resident 208) change in condition. These failures had the potential for Resident 208 to not obtain the proper treatment, not have consistent care given, not identify the best course of action for Resident 208's concerns, and potentially lead to harm up to and including death. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Provide preventive measures for pressure injuries (break down of the skin and underlying tissue) for one of two sampled residents (Resident 5). 2. Ensure weekly wound assessments for two of two sampled residents (Resident 5 and Resident 21). These failures had the potential to result in the development of additional pressure injuries and the inability to determine the healing progress of current wounds.

Inspectors wroteBased on interview and record review, the facility failed to complete a fall risk for assessment two of three sampled residents (Resident 209 and Resident 55). These failures had the potential for Resident 209 and Resident 55 to have unmet care needs and potential for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure five of five sampled residents (Resident 15, Resident 19, Resident 41, Resident 55, and Resident 56) were assessed to determine the level of risk for bed entrapment (an event in which an individual is caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or bed frame) prior to the application of bedrails. This failure places residents at risk for harm when bed entrapment risk assessment has not been completed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 135 and Resident 44) were free from medication error rate of greater than five percent (%) when two medication errors occurred within 29 opportunities resulting in a 6.9 % error rate. This failure had the potential for Resident 135 and Resident 44 not receiving the full therapeutic effects of the medication and potential for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of medication for one of 66 sampled residents (Resident 8) when medications were found at Resident 8's bedside table. These failures had the potential for medications to be administered incorrectly and unsafely.

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary staff was assigned to conduct assessment of food preferences for one of one sampled resident (Resident 56). This failure had the potential to result in unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pureed diet (a texture-modified diet useful for people who have difficulty chewing and swallowing foods and liquids) was served according to the physician's order for one of 66 sampled residents (Resident 8). This failure had the potential to adversely affect the resident's health.

Inspectors wroteBased on interview and record review, the facility failed to provide the minimum square footage as required by the regulation in 13 of the facility's resident bedrooms. This failure had the potential for insufficient space for residents' mobility, safety, and nursing care.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment orders were administered per physician orders for one of three sampled residents (Resident 1). This failure had the potential for worsening of Resident 1's wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 71 of 71 sampled residents residing at the facility when: 1a. Two of 35 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with multiple (approximately 15 pieces) rodent- (small gnawing mammals) like shiny black granular-size droppings 1/2 - ¼ inch (in - unit of measurement). 1b. A live mouse (small rodents with pointed snout) observed by Certified Nursing Assistant (CNA) 1 in room [ROOM NUMBER] (occupied by Resident 3, Resident 4, and Resident 5), room [ROOM NUMBER] (occupied by Resident 1 and Resident 2), and room [ROOM NUMBER] (occupied by Resident 6, Resident 7, and Resident 8) on 11/7/23, 11/8/23, and 11/9/23. 1c. A live mouse observed by one of 17 sampled residents (Resident 14) on 11/9/23. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of three sampled residents (Resident 1) Percutaneous indwelling central catheter (PICC) line (long tube that is inserted through a vein). This failure had the potential for infection.

Inspectors wroteBased on interview and record review, the facility failed to implement discharge planning for one of three sampled residents (Resident 1) when Resident 1 was discharged home with no medications. This failure resulted in Resident 1 missing to take her medications for two days after being discharged and had the potential to place Resident 1 at risk for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one of three sampled resident's (Resident 1) with personal hygiene when Resident 1 had dark debris under her long fingernails. This failure had the potential for Resident 1 to have skin breakdown and spread of infection.