Valley Palms Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent (IC-voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for a psychotropic (any prescription drug that alters chemical levels in the brain to affect a person's mind, emotions, or behavior) medication was not obtained from a resident who did not have the capacity to make decisions for one of three sampled residents (Resident 1). This deficient practice had the potential to violate Resident 1's right to make an informed decision, negatively affecting Resident 1's well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 5/4/2026. This deficient practice had the potential to result in hunger and frustration affecting 88 to 91 residents who were getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen storage surfaces were not of cleanable surfaces a. Racks in the walk-in refrigerator had chips and the paint was coming off. b. Four (4) of 4 shelves in the reach-in refrigerator had rust and amber discoloration c. [NAME] shelves in the dry storage area had chips on the edges. d. Shelves in the walk-in freezer had rust and amber discoloration. e. Thirty-five (35) of 45 residents' trays had chips and cracks and lost its glaze. f. [NAME] chopping board by trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). 2. Kitchen and storage areas were not free from dirt and debris. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. The dumpsters (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) surroundings were not free of trash and dry black liquid spills. b. The dumpster covers have more than three inches (in., a unit of measurement) gap in between each other and not completely covered. c. The dumpster body had dry spills. These failures had potential to attract birds, flies, insects, pests (animals or microorganisms that has a negative effect on humans) and possibly spread infection to 91 of 91 facility residents.

Inspectors wroteBased on observation, and interviews, the facility failed to ensure that five of five sampled residents (Resident 36, 54, 75, 79, 97) were informed of the location of the results of the most recent survey of the facility conducted by Federal or State surveyors. This deficient practice resulted in resident being unable to access important facility information, potentially impacting their awareness of care standards, rights, and overall involvement in their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for four of nine sampled residents (Resident 31, 75, 37, and 49) reviewed under environment facility task by failing to: 1. Ensure Resident 31's headboard was fixed in a timely manner and was not loose and wobbly, creating a risk of the headboard falling on the resident. 2. Ensure Resident 75's battery compartment cover for the television (TV) remote control was not broken and did not have a rubber band used to hold the batteries in place. 3. Ensure Resident 37 and 49 had a functional dresser drawer. These deficient practices violated the resident's right to a safe, clean, comfortable and homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure person centered care plans were developed and implemented for five of five sampled residents (Resident 53, Resident 14, Resident 4, Resident 31, and Resident 39) by failing to: 1. Monitor and assess Resident 53 for skin breakdown on affected sites. This deficient practice had the potential for recurrence of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). 2. Develop and implement Resident 14's comprehensive care plan for oxygen administration. This deficient practice had the potential to result in failure of the delivery of necessary care and services.3. Develop and implement a care plan for Resident 4's clonazepam (medication used to calm the brain and nervous system) use.4. [...]

Inspectors wroteBased on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care for two of two sampled residents (Residents 76 and 39) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for seven of thirteen sampled residents (Residents 4, 76, 110, 15, 31, 29, and 113) reviewed for accidents by failing to:1. Ensure Resident 4 and 29's beds were kept at the lowest position.2. Ensure Resident 76's floor mat was not placed halfway under the bed.3. Ensure Resident 110's bed remote control was within reach.4. Ensure Resident 15 did not have a bottle of hand sanitizer at the bedside.5. Ensure Resident 31 did not have a wobbly headboard that could fall on the resident's head.6. [...]

Inspectors wroteThe facility failed to ensure the safe and appropriate use of bed rails (BR - adjustable, rigid, plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for three of eight sampled residents (Resident 1 7 and 29) reviewed under the Accidents care area.1. For Resident 1 the facility failed to:a. Follow the physician's order to apply grab bars (sturdy, removable metal handles that attach to a bed frame or slide under the mattress). However, the facility applied one-half length bed side rails (one-half-length bed rail is a safety barrier that covers half of a bed, typically near the user's torso). (Side rails are used to prevent patients from falling out of the bed, and a grab bar can help them to pull themselves upright on the bed).b. Perform a one-half length bedside rails assessment.c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff did not have a complete performance review for the following: 1. Provide basic activities of daily living (ADLs - toileting hygiene, shower/bathing) care training for one of five sampled staff (Certified Nursing Assistant 1). 2. Provide annual performance evaluation for four of five staff (Registered Nurse [RN] 1, Treatment Nurse [TN] 1, Certified Nursing Assistant [CNA] 1, and Certified Nursing Assistant [CNA] 2). These deficient practices had the potential for lack of knowledge and training among the staff, leading to inadequate resident care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Residents 76 and 39) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provisions of pharmaceuticals services by failing to remove two expired medications from medication carts and mark six medications with an open date in two of four medication carts (Station A Middle medication cart and Station B medication cart). These deficient practices had the potential to result in administration of expired medications, reduced therapeutic effectiveness and compromised resident safety and medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when staff did not follow the portion size of grilled bratwurst, three (3) ounces (oz, unit of measurement), and served 1.5 oz portion size instead. This failure had the potential to result in decrease in food flavor, decrease in food and nutrient intake affecting 20 of 91 residents who are on regular diet, potentially resulting in unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature when hot foods were not served hot. This failure had the potential to result in 88 of 91 facility residents including Resident 53 at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on soft bite size level 6 diet (food that are bite sized pieces no more than 1.5 centimeters (cm., a unit of measurement) to 1.5 cm., soft, tender and moist food but with no liquid leaking or dripping from the food) received and consumed food in appropriate texture as prescribed by a physician. Residents were served minced and moist diet instead. This deficient practice had the potential to result in ineffective therapeutic diet, decreased in nutrient intake affecting 10 of 91 residents potentially resulting in weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the electrical and patient care equipment in safe operating condition for four of nine sampled residents (Residents 76, 31, 2,15, and 49) reviewed under environmental task by failing to ensure there were no frayed wires on the resident's bed remote controls. The deficient practice had the potential for residents to sustain accidents such as electrical shock and physical discomfort.

Inspectors wroteBased on observation, and interview, the facility failed to ensure the call light (an alerting device for residents to call a nursing personnel to assist them when needed) within reach of the resident for two of two sampled residents (Residents 10, 88). The deficient practice had the potential to place the resident at risk for delayed assistance, potentially affecting safety and timely care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advanced Healthcare Directive (a legal document indicating resident preference on end-of-life treatment decisions) was uploaded in a resident`s electronic health record to be readily available if needed for one of three sampled residents (Resident 15). The deficient practice violated the resident's rights and/or representative's right to ensure the resident's end-of-life treatment decisions were readily available for staff to honor and implement.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 75) had the right to be free from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of the resident's property, when Resident 75's [NAME] stick (a traditional tool used by many Native American tribes to ensure respectful communication during meetings) was missing and the facility failed to: - Update Resident 75's Resident Inventory List (a simple, detailed record of all personal belongings a person brings into an assisted living facility) with [NAME] stick on the resident's possession. - Replace reported lost [NAME] stick promptly. - Keep track of deliveries of the resident`s orders from outside vendors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents` drug regimen was free from unnecessary drugs for one of two sampled residents (Resident 4) reviewed for psychotropic medication (drugs that change how the brain works to treat mental health conditions) use by failing to ensure: 1. Resident 4's Lorazepam (a prescription medication used for the short-term treatment of severe anxiety, panic attacks, and insomnia) Oral Tablet 0.5 milligrams (mg, a unit of weight) had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). 2. Resident 4's Risperdal (is a medication that works in the brain to treat schizophrenia) had the current informed consent. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse (an action that intentionally causes harm or injures another person), neglect (failing to care for, pay attention to, or do something you are responsible for), exploitation or mistreatment (the act of treating someone unfairly), including injuries of unknown source and misappropriation of resident property (unauthorized, improper, or unlawful use or taking of someone else's assets, funds, or property), are reported immediately, but not later than two (2) hours after the allegation is made for one of thirteen sampled residents (Resident 76) reviewed for accidents by failing to report an injury of unknown origin (a physical injury that was not witnessed by anyone, and cannot be explained by the injured person) when the resident was found on the floor on 12/3/2025 and was noted [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a new Preadmission Screening and Resident Review level 1 (PASRR - a federal requirement to ensure that individuals with a mental disorder [MD - a person's mind makes it hard to think, feel, or act normally in daily living] or intellectual disability [ID - a person has trouble learning, understanding, or solving problems like most people their age] are properly screened and evaluated to determine appropriate placement and services in a nursing facility) for (1) of three (3) sampled residents (Resident 11), when Resident 11 was diagnosed by a Psychologist on 9/8/2026 with schizophrenia (a mental health condition that affects thinking, emotions, and understanding reality). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) is reviewed and revised by an interdisciplinary team (IDT, a group of experts from different fields like doctors, nurses, therapists, and social workers who work together closely to create a single, unified care plan for a patient) composed of individuals who have knowledge of the resident and his/her needs for one of thirteen sampled residents (Resident 76) reviewed for accidents by failing to review and revise the resident`s fall care plan to reflect an alleged unwitnessed fall on 12/3/2025. The deficient practice had the potential for delayed and unnecessary care for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and assess the healed pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) on the affected site for one of one sampled resident (Resident 53). This deficient practice had the potential for reopening of healed pressure ulcer for Resident 53.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the respiratory care provided to residents was consistent with professional standards of practice for one of one sampled resident (Resident 39) reviewed for respiratory care by failing to ensure Resident 39's oxygen via nasal cannula (a lightweight, flexible plastic tube that delivers extra oxygen (supplemental oxygen) directly into the nostrils via two small, comfortable prongs) tubing was labeled with the date it was last changed. The deficient practice had the potential for the resident to develop complications such as shortness of breath, desaturation (low levels of oxygen in the blood) and respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively manage a resident's pain for one of one sampled resident (Resident 12) by failing to reassess pain within one hour of administration of hydrocodone-acetaminophen (medication used for moderate to severe pain) oral tablet. This deficient practice placed Resident 12 at risk of inadequate pain relief and experienced health complications from their medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident receives care and services for the provision of hemodialysis (HD - filtering the blood of a person whose kidneys are not working normally) consisted with professional standard of practice by not implementing the fluid restriction and monitor fluid intake and output for one of two sampled residents (Resident 12). This deficient practice had the potential to cause fluid overload (excess water in the body) or dehydrating (insufficient water in the body) for Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately and safely provide pharmaceutical services to residents for one of one sampled resident (Resident 93) by failing to notify the pharmacist for review and proper labeling of a medication brought into the facility from an outside appointment prior to administration and failing to ensure the medication was incorporated into the resident's car plan. This deficient practice had the potential to result in medication errors, improper dosing, and adverse effects to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). Two medication errors out of 25 total opportunities contributed to an overall medication error rate of 8 % for one of four residents (Resident 45) observed during medication administration. For Resident 45, the facility failed to ensure: 1. The physician's order for vitamin B12 (a vitamin the body uses to make and support healthy nerve cells) dosage matched with the dosage for vitamin B12 available in the in-house supply. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document the placement of the low air loss mattress (LAL - a mattress designed to prevent and treat pressure wounds [localized damage to the skin and/or underlying tissue usually over a bony prominence]) for one of one sampled resident (Resident 53). This deficient practice had the potential not to receive the necessary care for prevention of pressure ulcers for Resident 53.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure the mobile linen cart was covered after removing needed linen supplies observed during resident screening. This deficient practice had the potential to cause cross-contamination (when harmful germs, chemicals, or allergens are unintentionally transferred from one object, surface, or person to another) of infection among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic use protocols and a system to monitor antibiotic use for two of three sampled residents (Residents 39 and 2) reviewed for antibiotic use by failing to ensure: 1. Resident 39's Hiprex (a prescription medicine used to prevent or reduce the frequency of chronic urinary tract infections [UTIs - an infection in the bladder/urinary tract] had a duration of use and had monitoring for adverse effects. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer the pneumonia (a lung infection) vaccine (medication that helps protect against pneumococcal infections, including invasive disease) yearly when the resident refused the immunization on 10/11/2023 for one of 5 sampled residents (Resident 54) reviewed for immunizations. This deficient practice had the potential to place residents at risk for respiratory infection including pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to document the explanation of the risk and benefits of refusing coronavirus disease 2019 (COVID-19 - a highly contagious respiratory illness caused by the SARS-CoV-2 virus, which first emerged in late 2019) vaccines for one of five sampled residents (Resident 36) reviewed for immunizations. This deficient practice had the potential to place residents at risk for respiratory infection including COVID-19.

Inspectors wroteBased on observation and interview, the facility failed to have an effective pest control program when a dead cockroach was found on the bathroom floor for one of nine sampled residents (Resident 78). This deficient practice had the potential in transmitting harmful bacteria to the residents and Resident 78 feeling disturbed.

Inspectors wroteBased on interview and record review, the facility failed to implement its written abuse policy and procedure (P&P) titled, Abuse and Neglect Exploitation or Misappropriation-Reporting and Investigating Policy designed to prevent, respond to and report abuse-related incidents after a physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) for one of three sampled residents (Resident 1) when staff did not immediately separate roommates Residents 1 and Resident 2 who had a physical altercation on 4/10/2026. This failure had the potential for Resident 1 to be subjected to further abuse from Resident 2 while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse within two hours for one of three sampled residents (Resident 1) when on 4/10/2026 there was an allegation that Resident 2 threw a bottle of lotion and landed on Resident 1's right shin. This deficient practice had the potential to place Resident 1 at an increased risk for further abuse which could have led to additional unreported incidents.

Inspectors wroteBased on interview and record review, the facility failed to revise a resident's care plans for one of four sampled residents (Resident 2). This failure had the potential to result in Resident 2 receiving inappropriate care because the care plan was not updated to address and meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly investigate allegation of resident-to-resident physical abuse for two of three sampled residents (Residents 1 and 2) by failing to interview and obtain a written statement from Certified Nursing Assistant 1 (CNA 1). This deficient practice had the potential to result in unidentified abuse in the facility and had the potential for further resident abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure changes in Resident 1's skin was measured as indicated in the facility's policy and procedure. This failure resulted in Resident 1's incomplete medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents (Resident 1) when on 12/9/2025 at 11 a.m., Resident 2 hit Resident 1 on the left cheek. This failure resulted in Resident 1 being grabbed in the left arm and getting hit on the left cheek by Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was medicated for pain as per physician's order. This deficient practice had the potential to result in Resident 3's uncontrolled pain.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 3) when Licensed Vocational Nurse 2 (LVN 2) administered sacubitril-valsartan (medication used to treat heart failure [heart was not pumping blood as well as it should to meet the body's needs]) to Resident 3 who had a blood pressure of 109/77 millimeter of mercury (mmHg-unit for measuring pressure) despite a physician's order to hold (suspend the medication) the sacubitril-valsartan for blood pressure below 110 mmHg. This failure had the potential to result in Resident 3's hypotension (low blood pressure).

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) when on 8/22/2025, at approximately 9:30 p.m., Resident 1 reported to facility staff that Resident 2 had hit her (Resident 1) legs. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) by failing to: 1. Complete a body assessment when on 8/22/2025 Resident 1 reported an allegation of physical abuse by Resident 2. On 8/22/2025, at approximately 9:30 p.m., Resident 1 informed Certified Nurse Assistant (CNA) 1 that Resident 2 hit Resident 1's legs with Resident 2's hands.2. Notify the physician of Resident 1's allegation of physical abuse by Resident 2, when on 8/22/2025, at approximately 9:30 p.m., Resident 1 informed CNA 1 that Resident 2 hit Resident 1's legs with Resident 2's hands. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who had a urostomy (a surgical procedure where an opening, is created in the abdomen to allow urine to exit the body) received proper care and services by: 1. Failing to notify the physician that Resident 1's urinary tubing had sediments (particles that can make your urine look cloudy or have visible specks) and cloudy urine. 2. Failing to assess, monitor and document Resident 1 for signs of urinary tract infection (UTI- an infection in the bladder/urinary tract) as indicated in Resident 1's care plan. 3. Failing to monitor and document urine output in milliliter (ml-unit of volume) as per physician order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained the resident's dignity for one of the three sampled residents (Resident 1) by failing to ensure Resident 1's urinary collection bag was covered with a privacy bag. This failure had the potential to negatively affect Resident 1's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person-centered care plan for one of three sampled residents (Resident 1) by failing to monitor, record and report to the physician signs of urinary tract infection (UTI- an infection in the bladder/urinary tract) as indicated in Resident 1's Care Plan for urostomy (a surgical procedure where an opening, is created in the abdomen to allow urine to exit the body). This failure had the potential for delayed provision of necessary care and services and had the potential for the development of UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to ensure Resident 2's urinary catheter drainage bag had a dignity bag (a bag used to cover and hold the catheter drainage or collection bag so it would not be visible). This deficient practice had the potential to affect Resident 2's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to ensure Resident 2's urinary catheter drainage bag was not touching the floor. This deficient practice had the potential to cause Resident 2 urinary catheter-associated complications including urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra]), discomfort, and pain.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Change in a Resident's Condition or Status, for one of three residents (Resident 1) when the facility failed to notify the Medical Doctor (MD 1) and the Family Member 1 (FM 1) that the facility did not collect the ordered urinalysis (UA- a medical test that examines urine samples) with a culture and sensitivity test (CS- tells you if bacteria are present in a sample from your body [like urine or a wound], and if so, which antibiotics are most likely to effectively kill those specific bacteria). This deficient practice resulted in a delay of delivery of care and services to Resident 1 who was diagnosed with a urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on interview and record review, the facility failed to complete a physician ordered urinalysis (UA- a medical test that examines urine samples) with a culture and sensitivity test (CS- tells you if bacteria are present in a sample from your body [like urine or a wound], and if so, which antibiotics are most likely to effectively kill those specific bacteria) for one of three sampled residents (Resident 1). This deficient practice resulted in the delay of care and services to Resident 1 who was diagnosed with a urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs (requirements that a person has in order to be well such as food) for one of one sampled resident (Resident 1) on puree diet (a texture modified diet that consists of smooth foods with pudding-like consistency that are easy to swallow) by not following the recipes for puree bread and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks). On 1/19/2025, Resident 1 was served puree bread that was too sticky and did not fall during the spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) at lunch. [...]

Inspectors wroteb. During a review of Resident 53's admission Record, the admission Record indicated the facility admitted the resident on 4/28/2021 and readmitted the resident on 12/10/2024 with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD - irreversible kidney failure), and dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), glaucoma (an eye condition causing gradual loss of sight), and dementia (a progressive state of decline in mental abilities). During a review of Resident 53's MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident received care consistent with professional standards of practice to prevent pressure injury (PI - the breakdown of skin integrity due to pressure) for three (3) of four (4) sampled residents (Residents 242, 24, and 26) investigated under pressure injury by: 1. Failing to ensure Resident 242 was provided a low air loss mattress (LALM - a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) when the resident had Stage 4 PI (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the right buttock upon admission to the facility. 2. Failing to perform an accurate assessment of Resident 242's Stage 4 PI. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was assessed after dialysis treatment and to document the assessment for one of one sampled resident (Resident 76) investigated during review of dialysis care area. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment.

Inspectors wroted. During a review of Resident 62's admission Record, the admission Record indicated the facility admitted the resident on 6/30/2022 and readmitted the resident on 12/19/2024 with diagnoses that included essential (primary) hypertension (high blood pressure with an unknown cause), aphasia (a disorder that makes it difficult to speak) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), and angina pectoris (chest pain or discomfort that occurs when the heart muscle doesn't receive enough oxygen). During a review of Resident 62's MDS dated [DATE], the MDS indicated the resident usually was able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for oral hygiene, lower body dressing, toileting, and bathing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for 88 of 92 residents when on 1/19/2025 [NAME] 1 did not prepare the breakfast omelet and used scrambled eggs for 88 residents for breakfast. This deficient practice had the potential to result in an increased food and nutrient intake resulting in unintended (not done on purpose) weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs for 88 out of 92 residents when on 1/19/2025 [NAME] 1 did not prepare the breakfast omelet and used scrambled eggs for 88 residents for breakfast. This failure had a potential to result in 88 the facility residents to be at risk for unplanned (not done on purpose) weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Resident foods were not labeled and dated. 2. Staff foods were stored in the kitchen refrigerator. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 88 of 92 medically compromised residents who received food.

Inspectors wroted. During a review of Resident 246's admission Record, the admission Record indicated the facility originally admitted the resident on 12/5/2024 and readmitted in the facility on 1/17/2025, with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), lack of coordination, and generalized weakness. During a review of Resident 246's History and Physical (H&P) dated 1/18/2025, the H&P indicated Resident 246 had the capacity to understand and make decisions. During a review of Resident 246's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2024, the MDS indicated the resident had an intact cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 246 required supervision or touching assistance with eating; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Residents 83) reviewed for unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) medications was free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 83's use of lorazepam (a psychotropic medication use to treat feelings of anxiousness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a patient when in need) was withing reach for one of two sampled residents (Resident 16) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 1 resident (Resident 247) investigated under the pain management care area by failing to develop a care plan addressing the resident's screaming behavior. This deficient practice had the potential to cause a delay in the delivery of necessary care and services the resident need.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services necessary to maintain good nutrition for one of one sampled resident (Resident 242) investigated under the activities of daily living (ADLs - routine/tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) care area by failing to ensure Certified Nursing Assistant 9 (CNA 9) provided assistance to Resident 242 with meals. This deficient practice had the potential to result in Resident 242 having weight loss, dehydration, or nutritional problems.

Inspectors wroteBased on interview and record review, the facility failed to provided needed care and services that are resident-centered for one of one sampled resident (Resident 8) reviewed under General care area when the facility failed to follow up Resident 8's lab draw for phenobarbital (medication used to control seizure [ (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) as ordered by the physician. This deficient practice had the potential to result in under treatment may cause ineffective seizure control or over treatment which may cause toxicity.

Inspectors wroteb. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 3/11/2024 and readmitted the resident on 11/30/2024 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), difficulty swallowing, and insomnia (inability to sleep). During a review of Resident 7's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required partial/moderate assistance from staff for personal hygiene and substantial/maximal assistance from staff for toileting, upper body dressing, and mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label the open date of Senna (a natural laxative that comes from the leaves and fruit of the senna plant) for one of two Medication Carts (Medication Cart 2 [MC 2]). This deficient practice had the potential for the medication to be ineffective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments for three of five sampled medications carts and treatment cart (Medication Cart B, Middle Cart, Treatment Cart B) when Medication Cart B, Middle Cart was not locked on 11/27/2024/2024, at 6:17 a.m. and treatment cart B was not locked on 11/27/2024, at 6:30 a.m This deficient practice could lead other residents or unauthorize staff have an access in medications.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin per physician's order to one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to have uncontrolled blood sugar.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for two of three sampled residents (Resident 2 and Resident 3) when on [DATE] at 6 p.m. Resident 1 expired in the facility and was left in his room that he shared with Resident 2 and Resident 3 until his (Resident 1's) dead body was moved on [DATE] at 7 a.m. This deficient practice had the potential to affect Resident 2's and Resident 3's homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to maintain the highest practicable psychosocial well-being for two of three sampled residents (Resident 2 and Resident 3) when the social services department did not provide follow-up visits to Resident 2 and Resident 3 after their roommate (Resident 1) expired (died) on [DATE] at 6 p.m. This deficient practice had the potential for Residents 2 and 3's stress and anxiety to increase.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified timely for one of three sampled residents (Resident 1). On 5/30/2024 at 9:10 a.m., Resident 1 had a pulse rate (the number of times the heart beats per minute) of 126 and physician was not notified until 12:40 p.m. This deficient practice resulted in the delay of obtaining appropriate instructions from the physician for proper management.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) to address Resident 1's tachycardia (elevated pulse rate) on 5/30/2024. This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to ensure metoprolol tartrate (medication used to treat high blood pressure) was not given to Resident 1 on 6/2/2024 at 9 a.m., 6/3/2024 at 9 a.m. and 5 p.m., as per physician's order. This deficient practices had the potential to result in medication error and delay in necessary care and had the potential to result in ineffectively managed hypertension (uncontrolled elevated blood pressure) for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to prepare and orient a resident to ensure a safe discharge for one of three sampled residents (Resident 1) by: 1. Failing to ensure Resident 1 was discharged to a board and care (a residential home that has been licensed by the California Department of Social services to house and provide non-medical care for six elderly residents) as per physicians' order. 2. Failing to document independent living facility's contact number in Resident 1's medical record. 3. Failing to ensure Placement Coordinator (PC- assist in locating facilities in your local area that will meet your caregiving needs) was informed that physician's order was to discharge Resident 1 to board and care. These deficient practices placed Resident 1 at risk for unsafe discharge. On 7/1/2024 Resident 1 was discharged to an independent living (unlicensed facility).

Inspectors wroteBased on interview and record review, the facility failed to ensure an engaged governing body was responsible for establishing and implementing policies regarding the management of the facility for one of three sampled residents (Resident 2). On [DATE] at 6 p.m., Resident 2 expired in the facility and was not picked up by mortuary services until 911 (emergency services) was called the following day of [DATE] at 8:50 a.m. This deficient practice resulted to Resident 2's dead body stayed at the facility for more than 12 hours.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was accurate documentation for one of three sampled residents (Resident 1) by failing to document the independent living facility's contact number in Resident 1's medical record. This deficient practice placed Resident 1 at risk for an unsafe discharge. On 7/1/2024 Resident 1 was discharged to an independent living (unlicensed facility).

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess three of three sampled residents (Resident 1, 2, and 3) for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) from bed rails (adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths, i.e., grab bars, assist bars, side rails, safety rails, mobility bar) when Resident 1, 2, and 3 did not have an entrapment risk assessment performed prior to installation of a bed rail. This deficient practice had the potential to result in psychosocial harm, physical harm from entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) and death of residents.

Inspectors wroteBased on interview and record review, the facility failed to provide an environment that is free from accidents when one of three sampled residents (Resident 1) was not accurately evaluated for fall risk when Resident 1 ' s Fall Risk Assessment, dated 4/11/2024, indicated Resident 1 was not at risk for falls. This deficient practice had the potential for the facility to not develop and implement a plan of care to prevent falls and injuries in residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an accident and injury for one of two sampled residents (Resident 28), who was assessed as a fall risk, was unable to move from the neck down, was dependent on staff for bed mobility, dressing, and personal hygiene, and was on a low air loss mattress (LALM, a device that operates using a blower-based pump designed to circulate a constant flow of air; the air mattress is covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure). The facility failed to ensure Certified Nursing Assistant 5 (CNA 5) implemented the facility's policy and procedure (P&P) on Repositioning by not using two-person physical assistance while giving care and turning Resident 28 in bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan by: 1. Failing to ensure Resident 27 had a care plan addressing the use of bolster pillows in the resident's bed for one of one sampled resident investigated during review of physical restraints use. Cross reference to F604 2. Failing to ensure Resident 345's dialysis care plan intervention of monitoring intake and output was implemented for one of one sampled resident investigated during review of dialysis care area. 3. Failing to ensure Resident 37 and Resident 68 had a care plan addressing the use of antibiotics (medication used to treat infections) for two of five sampled residents investigated during review of antibiotic stewardship. 4. Failing to ensure Resident 80 had a care plan addressing self-administration of medication. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled resident (Resident 67) investigated during medication observation pass was free of any significant medication error when: 1. Licensed Vocational Nurses failed to administer metoprolol tartrate (medication that works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure [the pressure of blood pushing against the walls of your arteries]) to Resident 67 as prescribed for three out of 18 days. This deficient practice had the potential for Resident 67's blood pressure to be elevated. 2. Licensed Vocational Nurses failed to rotate injections sites for Enoxaparin (an anticoagulant known as a blood thinner used to prevent and treat blood clots) for 4 out of 18 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label a multi-dose container of multivitamin with minerals (a combination of different vitamins and minerals) with an open date for one of three sampled residents (Resident 67) residents observed during medication administration. 2. Ensure zolpidem oral tablets (controlled medication a [drug or chemical whose manufacturer, possession, or use is regulated by a government] used to treat insomnia [trouble sleeping]) were stored in the bubble pack (a packaging that have a preformed plastic pocket or shell where a product sits securely in place) with intact seal and not covered with tape affecting Resident 63 in one of two inspected carts (Station A Med Cart 1). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food services safety and that food maintained its nutritive value and was not compromised by prolonged food storage when multiple items were noted without an open date or use by date. This deficient practice had the potential to result in 91 out of 95 residents receiving food items that are expired and placed residents at risk for developing foodborne illness symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain an infection control program by failing to: 1. Ensure LVN 2 performed hand hygiene to one of one sampled resident (Resident 66) observed during medication administration. 2. Ensure Resident 146's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was kept off the floor for one out two sampled residents investigated addressing the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) or urinary tract infection (UTI, an infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra) care area. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality during one (Resident 146) of one random observations by failing to ensure the resident's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was covered with a privacy bag. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's self-administration of medications was appropriate and safe for one of one sampled resident (Resident 80) investigated during a random observation by failing complete a Medication Self-Administration Assessment for Resident 80 before leaving medications at the resident's bedside. This deficient practice had the potential to result in unsafe medication management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was within reach for two of five sampled residents investigated during review of environment facility task Resident 27 and Resident 33). These deficient practices had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries.

Inspectors wroteBased on interview and record review, the facility to ensure a current copy of the advance directive (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was in the resident's medical records for one of two sampled residents (Resident 144) investigated during review of advance directive care area. This deficient practice had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from physical restraint for one of one sampled resident (Resident 27) investigated during review of use of physical restraints when bilateral bolster pillows were tucked under the fitted sheet to prevent the resident from getting out of bed. This deficient practice placed Resident 27 at risk for being restricted with movement and had the potential to violate the resident's rights to be free from any restraints that are imposed for reasons other than the treatment of the resident's medical symptoms.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) addressing hospice care within 48 hours of admission for one out of two sampled residents (Resident 144) investigated during review of hospice and end of life care area. This deficient practice had the potential for Resident 144 not to receive the appropriate care and treatment specific to his needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary treatment and services for one of three (Resident 52) sampled residents investigated during review of pressure ulcer/injury (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) care area by failing to follow the manufacturer's guidelines for the use low air loss (LAL) mattress. This deficient practice had the potential to delay the healing of Resident 52's pressure injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to secure a resident's urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) with a securement device for two of three sampled residents (Resident 144 and Resident 146) investigated during review of urinary catheter care area. This deficient practice had the potential for the residents' urinary catheters to be dislodged requiring reinsertion of the catheter tubing and increase the potential for the residents to obtain a urinary tract infection (UTI, an infection that affects part of the urinary tract-kidneys, ureters, urinary bladder, and the urethra).

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice to one of one sampled resident (Resident 347) during random observation of residents with peripheral intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by failing to: 1. Follow-up with the physician to obtain an order to discontinue the peripheral intravenous catheter after the physician ordered to discontinue monitoring the IV site for signs and symptoms of inflammation/infiltration (when some of the fluid leaks out into the tissues under the skin where the catheter has been put in to the vein) on 2/11/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for one of one sampled resident (Resident 144) during a random observation by failing to ensure Resident 144's nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) was properly applied to ensure the resident receive the oxygen ordered by the physician. This deficient practice had the potential to affect Resident 144's comfort by not getting enough oxygen in the system causing shortness of breath leading to hypoxia (low levels of oxygen in the body).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of seven sampled residents (Resident 2) investigated during review of dining observation task was provided food that accommodated the resident's preference when the resident was served food (pork) that was on the resident's list of food dislikes. This deficient practice placed the resident at risk for having poor appetite that could potentially result in weight loss.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that are complete and accurately documented for one of three (Resident 92) investigated during review of closed records by failing to ensure the licensed nurse documented in the resident's progress note the accurate time of when cardiopulmonary resuscitation (CPR, an emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped) was performed to Resident 92. This deficient practice had the potential to result in the resident's medical record containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) in a consistent manner for one of one sampled resident (Resident 144) investigated during review of hospice services by failing to: 1. Ensure Hospice Provider 1 (HP 1), provided the facility a calendar of hospice aide schedule of visits. 2. Ensure there was documented evidence that the hospice aide visited the resident as indicated in the plan of care. These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate. That means prescribing the right drug at the right dose at the right time for the right duration) for one of five sampled residents (Resident 68) by: 1. Failing to document the completion date of ciprofloxacin (medication used to treat infection) eye drop in the Infection Prevention and Control Surveillance Log dated 2/2024. 2. Failed to provide documented evidence that Surveillance Data Collection forms were completed and matched the Infection Prevention and Control Surveillance Log for the month of 2/2024 for Resident 68. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer pneumococcal vaccine (helps protect children and adults from various types of pneumococcal bacteria causing lung infection) to three of five sampled residents (Resident 37, 38 and 68) after the three resident had provided their consents to receiving the vaccine. This deficient practice placed Residents 37, 38 and 68 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for one of five sampled residents investigated during review of environment task (Resident 54) by failing to: 1. Ensure Resident 54's bed controller was in working order (device used to change the height and angle of the bed). 2. Ensure Resident 54's bed mattress provided support to keep him comfortable. These deficient practices had the potential to affect Resident 54's comfort and places the resident at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled resident (Resident 1) by: 1. Failing to accurately document time physician was called on 12/13/2023 when Resident 1 had coughed out blood. 2. Failing to completely document assessment and interventions provided to Resident 1 when he had an episode of shortness of breath (sob) and hematemesis (vomiting of blood) on 12/14/2023. 3. Failing to monitor, document and report changes in lung sounds on auscultation (the action of listening to sounds from the heart, lungs, or other organs) as per Resident 1 ' s care plan. These deficient practices had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate and incomplete information entered into Resident 1 ' s medical record.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 1) by: 1. Failing to notify the attending physician timely when Resident 1 had an episode of shortness of breath (sob) and hematemesis (vomiting of blood) on 12/14/2023 at 7:30 a.m. The Change of Condition (COC) form dated 12/14/1023 indicated the attending physician was notified at 8:30 a.m. 2. Failing to immediately call the paramedics (are allied health professionals whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system) when Resident 1 ' s attending physician order to transfer the resident to General Acute Care Hospital (GACH) on 12/14/2023 at 8:30 a.m., via emergency number 911. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biological) for one of three sampled resident (Resident 1) by failing to ensure resident was not administered Bystolic (medication used to treat high blood pressure) on 12/13/2023 at 9 a.m., when the resident ' s systolic blood pressure was less than 110 as ordered by physician. This deficient practice placed Resident 1 at risk for hypotension (low blood pressure).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice, by preventing pressure ulcers (injury to the skin and underlying tissues resulting from prolonged pressure on the skin by the bone) from worsening, for one of four residents (Resident 1) by failing to implement an intervention in the care plan to reposition Resident 1. This deficient practice resulted in failure to deliver necessary care and services, and the potential to result in Resident 1 ' s pressure ulcers worsening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of four sampled residents (Residents 4), by failing to: a. Ensure Case Manager (CM) perform hand hygiene (hand washing with soap and water or use of alcohol-based hand sanitizer) after touching Resident 4 ' s bathroom doorknob and after exiting Resident 4 ' s room. b. Ensure Restorative Nursing Assistant 1 (RNA 1) wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly with both elastic straps on. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with the facility ' s policy and procedures (P&P), plan of care, and physician ' s orders to promote healing of pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) and to promote PU healing and prevent infections for two of three sampled residents (Residents 4 and 5). The facility failed to: 1. Set the low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) to the appropriate setting per manufacturer ' s recommendation for Residents 4 and 5. 2. Ensure Resident 4 ' s PU dressing (a type of bandage used to cover wounds) was kept clean and dry. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4) was treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life by failing to ensure the urinary catheter drainage bag was fully covered by the dignity bag (a dark colored bag that conceals the front and back of the urine drainage bag). This deficient practice had the potential to affect Resident 4 ' s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure (P&P) on Residents Call System, Residents, for one of three sampled residents (Resident 1), when Resident 1 activated his call light (device used by residents to signal staff for assistance) and was not responded to until 15 minutes after the call light was activated. This deficient practice had the potential to for residents to feel frustrated and to not be attended to during an emergent situation, such as a fall or respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidential personal information for one of five sampled residents (Resident 4) was protected. The clinical records of Resident 4 were left unattended on the treatment cart computer. This deficient practice had the potential to violate Resident 4 ' s rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to communicate necessary information related to discharge for one of three sampled residents (Resident 3) when Resident 3 ' s Discharge Instructions Form/Recapitulation of Stay, dated 8/14/2023, did not indicate the following: - Reason for Discharge - Primary Physician - Medical Equipment Arrangements - In Home Care or Services - Emergency This deficient practice had the potential for Resident 3 ' s responsible person (RP) to not know who to contact regarding post-discharge care.