Valley Village Care Center

Inspectors wroteBased on interview and record review, the facility failed to communicate accurate information to the receiving provider (GACH - General Acute Care Hospital) regarding resident's medication administration record for one of three sampled residents (Resident 1). On 5/19/2026, Resident 1 was transferred to GACH1 for a surgical procedure to be performed under the anesthesia (a medicine that stops the person from feeling pain signals from the nerves in the brain). This deficient practice resulted in rescheduling a surgical procedure and had the potential to negatively affect Resident 1's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for nothing by mouth (NPO- resident should not consume any food, beverages, or oral medication. It is commonly used for safety before surgery or procedures that require anesthesia to prevent serious complications) for one of three sampled residents (Resident 1). These deficient practices had the potential to delay care and negatively affect Resident 1's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of three sampled residents (Resident 2) were complete and accurate and were maintained in accordance with accepted professional standards and practice. The facility failed to:1. Ensure complete documentation of Resident 2's Situation, Background, Assessment, and Recommendation Communication (SBAR) form, dated 5/19/2026. 2. Ensure accurate documentation of Resident 2's Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, history of falls, vision, balance, mobility, medications) form. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two of two sampled residents (Residents 8 and 1) reviewed under Environment task and one of one sampled resident (Resident 50) during a random observation by failing to: 1. Ensure Resident 8 and 1's window was well sealed after the installation of a temporary portable Air Conditioner (AC - a freestanding, self-contained cooling unit) unit. 2. Maintain the cleanliness of Resident 50's electric desk fan. These deficient practices had the potential to negatively affect the residents' quality of life.

Inspectors wroteBased on observation, 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 two of five sampled residents (Resident 23 and 7) reviewed during the Medication Administration task, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 3 administered medication in the form prescribed by the physician and per facility policy and procedure (P&P) when LVN 3 crushed (pressing very hard so that the shape is destroyed and forms a soft powder) and administered Resident 23's crushed medications without a physician's order on 5/6/2026 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu and did not meet nutritional needs for twelve (12) out of 12 Residents on pureed diet when Speech Therapist (SLP) 1 instructed the [NAME] (CK) to add liquid thickener to the blended food not measured according to specified recipe on adding substitutes. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents, cause resident dissatisfaction, and increase food and nutrient intake resulting to unintended (not done on purpose) weight loss. Cross-reference F805.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on pureed diet (diet consisted of food that are blended, whipped, or mashed into a smooth, thick consistency similar to pudding) received meals that were runny and did not hold its form for twelve (12) out of 12 Residents on pureed diet. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents, cause resident dissatisfaction, and increase food and nutrient intake resulting to unintended (not done on purpose) weight loss. Cross-reference F803.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 7) reviewed for medication administration task and two of three sampled residents (Resident 40 and 64) by failing to: 1. Ensure that Licensed Vocational Nurse (LVN) 2 accurately documented Resident 7's request for a change in the medication administration timing and instead recorded the request as a refusal. This deficient practice had the potential to result in inaccurate information entered in Resident 7's medical record. 2. Accurately document Resident 64`s fluid intake in the Medication Administration Record (MAR, a list of scheduled medications and other instructions ordered by the medical doctor) on May 1,2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the electrical and resident care equipment in safe operating condition by failing to ensure that the Heating, Ventilation, and Air Conditioning (HVAC - are systems used to manage indoor climate and air quality) unit was in a safe and proper working condition starting on 9/10/2025 for three of three sampled residents (Residents 8, 1, and 7), in (4) of 4 residents rooms (rooms 36, 37, 38, and 39), and 4 of 4 other facility rooms including the rehabilitation therapy room, the Director of Nursing (DON)'s office, activity staff office room, and laundry room. These deficient practices had the potential to result in residents being exposed to dramatic changes in room temperature, poor ventilation and air quality which can lead to worsened respiratory symptoms and increase respiratory infection risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a medication self-administration assessment for one of three sampled residents (Resident 15) reviewed under the Accidents care area when Resident 15 kept oxymetazoline HCl nasal spray (a medication to treat congestion in the nasal passage) at the bed side for self-administration. This failure had the potential to result in violating Resident 15's right to self-administer medications and had the potential for the resident to experience adverse effects (an undesired effect of a drug or other type of treatment) from the self-administered medication. Cross-reference F689.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that formulation of an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was discussed for one (1) of 1 sampled resident (Resident 21) reviewed under the advance directive care area. This deficient practice violated the resident`s rights and/or the resident`s representative`s right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident was treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of three sampled residents (Resident 64) reviewed for physical restraints by failing to ensure that Resident 64 did not have two pillows tucked on both sides under the fitted sheet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of two sampled residents reviewed for respiratory care by failing to implement a care plan on the use of Bilevel Positive Airway Pressure (BIPAP - a non-invasive device used to help people breathe more easily, typically while sleeping or in a hospital setting) when the physician order was not followed to rinse and air dry after each use. This deficient practice had the potential to result in a delay of nursing care for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a comprehensive care plan for one of three sampled residents (Resident 49) reviewed for pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) when the facility failed to revise Resident 49's care plan to reflect the physician's order to offload (relieve pressure) Resident 49's left foot for a stage one (1) pressure ulcer/injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). This failure resulted in the lack of an individualized plan of care for Resident 49. Cross-reference F686.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent worsening of a pressure ulcer/injury stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) when one of three sampled residents (Resident 49) did not have a pillow under the left foot, per the physician's order. This failure had the potential to result in worsening of Resident 49's pressure ulcer. Cross-reference F657.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents by failing to: 1. Ensure oxymetazoline HCl nasal spray (a medication to treat congestion in the nasal passage) was not left unattended and readily available for self-administration in a resident's shared room for one of three sampled residents (Resident 15). This failure had the potential to result in residents obtaining medication without staff knowledge resulting in unsupervised self-administration and accidental ingestion causing harm to residents. 2. Ensure the right side floor mat was in place while the resident was in bed and left unattended for one of three sampled residents (Resident 10). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one of one sampled resident (Resident 28) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure the urinary catheter tubing did not have a dependent loop while hanging on the side of the bed. This deficient practice had the potential for Resident 28's urine not to flow freely, and which may lead to the development of a UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) of 1 sampled resident (Resident 73) reviewed for tube feeding when the water flush bag was not changed according to the manufacturer's recommendations. This deficient practice had the potential to result in altered nutritional status such as dehydration (when the body uses or loses more fluid than it takes in), malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients), and complications associated with enteral feeding such as gastrointestinal (GI - relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Resident 8 and 43) reviewed for respiratory care by failing to: 1. Follow the physician order to rinse and air-dry Resident 8's Bilevel Positive Airway Pressure (BIPAP, a non-invasive device used to help people breathe more easily, typically while sleeping or in a hospital setting) after each use. 2. Ensure Resident 43's oxygen (O2) via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. These deficient practices had the potential for the residents to develop complications such as shortness of breath and respiratory infections. Cross-reference F656.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%) due to seven (7) errors observed out of 29 total opportunities (error rate of 24.14 %) for one of five sampled residents (Resident 23) observed during the Medication Administration Task. The medication errors occurred when Licensed Vocational Nurse (LVN) 3 crushed (pressing very hard so that the shape is destroyed and forms a soft powder) and administered seven crushed medications to Resident 23 without a physician's order on 5/6/2026 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's food preference was honored for one (1) out of five (5) sampled residents (Resident 43) reviewed during dining observation task by failing to ensure Resident 43 was provided food that accommodated the resident's preferences when the resident was not served ice cream as indicated in the meal ticket. This deficient practice placed Resident 43 at risk for decreased food intake which could potentially result in weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to discard one (1) yellow bell pepper with white and gray discoloration inside a green tray. This deficient practice had the potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 90 out of 92 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of one sampled resident (Resident 52) reviewed under hospice care area by failing to: 1. Ensure Resident 52's hospice plan of care was followed for hospice aide visit once a week when the hospice aide (HA) did not visit on 2/13/2026 and 2/20/2026. 2. Ensure Resident 52's Registered Nurse (RN) Visit Note did not indicate that a hospice aide evaluation was completed on 2/13/2026. These deficient practices had the potential to negatively affect Resident 52's physical comfort, psychosocial well-being, and had the potential to result in a delay or lack of necessary care and services.

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 for one (1) of 1 sampled resident (Resident 89) reviewed under infection control care area by: 1. Failing to ensure there was a physician's order for the Enhanced Barrier Precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO - microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics (medication used to treat bacterial infections)] that uses targeted gown and glove use during high contact resident care activities) due to presence of wound on the left foot. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate assessment was conducted for one of one sampled resident (Resident 72) reviewed during the Position, Mobility care area and one of two sampled residents (Resident 31) by: 1. Failing to ensure the Minimum Data Set (MDS - a resident assessment tool) Assessment was coded correctly to indicate the restorative nursing staff provided the application and removal of splint for Resident 72. This deficient practice had the potential to result in missed interventions. 2. Failing to ensure the MDS Assessment was transmitted accurately when Resident 31 who did not receive an antibiotic (a type of medication that treats bacterial infections) was coded as taking the medication. This deficient practice had the potential to cause confusion and delay in the delivery of necessary care and services to Resident 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure code pink (the facility's code to call when a resident is missing) was called immediately when one of three sampled residents (Resident 1) was missing per facility's undated policy and procedure titled, Missing Resident,. This deficient practice resulted in Resident 1 missing medications placing Resident 1 at risk for potential harm.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards: 1. For one of one sampled resident (Resident 32) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) the insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of 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). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five of six sampled residents (Resident 23, Resident 92, Resident 95, Resident 297, and Resident 32) reviewed for accident care area were free of accidents when: 1. Resident 23's pathway to the bathroom (restroom/toilet) was obstructed with his roommate's wheelchair. This deficient practice had the potential for Resident 23 to fall while waiting to get into the bathroom. 2. Resident 92's acetaminophen (pain medication) two tablets and enoxaparin (treats and prevents blood clots) were left on top of the medication cart unattended and out of the sight of Licensed Vocational Nurse 4 (LVN 4). This deficient practice had the potential for Resident 92's medications to be taken by another resident or other person. 3. [...]

Inspectors wroteBased on observation, 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 five of nine sampled residents (Residents 25, 32, 41, 58, and 2) by failing: 1. To ensure Resident 25's Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD-a chronic lung disease causing difficulty in breathing] and asthma [a chronic lung disease that makes breathing difficult in adult]) and two over-the-counter multidose medications were labeled with dates the medications were opened for two of four medication carts reviewed. 2. To ensure Resident 32's physician order was followed. On 2/16/2025 at 7:43 a.m., LVN 1 administered Norco (medication used to treat pain) to Resident 32 with a pain level of zero. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards): 1. For one of one sampled resident (Resident 32) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) the insulin administration sites. [...]

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. Temperatures were not checked on 2/13, 2/14 and 2/15 for the dry storage room. 2. The following food items were not discarded: - Corn flakes with use by date of 2/8/25 - Breadcrumbs with use by date of 1/10/25 - Beans with use by date of 2/10/25 - [NAME] cheese with use by date of 2/14/25 3. Food items were not properly labeled with either missing received date, open date and/or use by date for: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement infection control measures by failing to ensure: 1. Prostat (supplement for dietary management of wounds and other conditions requiring increased protein) bottle was kept in a clean and in sanitary condition before and after use for two of four sampled medication carts (Medication Carts 1 and 4). 2. The Maintenance Director (MS) and the Infection Preventionist (IP) were able to identify signs of legionella (a severe form of pneumonia - lung inflammation usually caused by infection) as indicated in the legionella water management program. These deficient practices had the potential to result in unidentified cases of legionella and the spread of infection in the facility as well as prostat bottle contamination (the process of making something dirty).

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 for one (1) of 1 sampled resident (Resident 13) reviewed for dignity when Certified Nursing Assistant 5 (CNA 5) failed to provide privacy while providing care to Resident 13. This deficient practice had the potential to affect the resident's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to obtain written verification of informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for two of five sampled residents (Resident 32 and 76), or resident representative by failing to: 1. Ensure Resident 32's choice to consent (give permission) or not to consent for the use of bupropion (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]) was documented in the informed consent. 2. Ensure Resident 76's choice to consent or not to consent for the use of venlafaxine (medication used to treat depression) was documented in the informed consent. [...]

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 (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two (2) of three (3) sampled residents (Residents 1 and 77) 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 call for assistance.

Inspectors wroteb. During a review of Resident 84's admission Record, the admission Record indicated the facility admitted Resident 84 on 11/30/2024 and readmitted the resident on 12/23/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following a cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) affecting the right dominant side, encephalopathy (brain damage or disease that affects the brain's structure or function), and aphasia (a language disorder that makes it difficult to communicate). The admission Record indicated Resident 84 had a Resident Representative. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Change in a Resident's Condition or Status (COC), for one of two sampled residents (Resident 50) by not promptly informing Resident 50's resident representative when on 1/23/2025 Resident 50 had a laboratory result of low iron level (a condition where your body has too few iron stores). This deficient practice resulted to violation of Resident 50 or the resident representative's right to be notified.

Inspectors wroteBased on observation, interview, and record review, facility failed to maintain privacy of confidential information when Licensed Vocational Nurse 4 (LVN 4) left the electronic health record (EHR- a digital version of a patient's paper chart) opened, unattended and out of view for one of one sampled resident (Resident 92) during a random observation. This deficient practice violated Resident 92's right to privacy and confidentiality of their medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one (1) of three (3) sampled residents (Resident 32) reviewed under Environmental Task by failing to ensure Resident 32's right floor mat was not torn off on the right lower corner. This deficient practice had the potential to negatively affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of one sampled resident (Resident 20) reviewed for physical restraints care area by failing to ensure Resident 20 had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and a care plan for restraint bed placed against the wall. [...]

Inspectors wroteBased on interview and record review, the facility: 1. Failed develop a comprehensive person-centered care plan (CP-a document outlining a detailed approach to care customized to an individual resident's needs) timely for one of one sampled resident (Resident 2) reviewed for anticoagulant (blood thinner - prevents blood clots or keep an existing clot from getting worse) when Resident 2's care plan addressing the use of heparin (anticoagulant) was developed 25 days after readmission. 2. Failed to develop a comprehensive person-centered care plan for one of two sampled residents (Resident 50) reviewed for Change of Condition (COC) care area when Resident 50 had a COC of low iron laboratory results (too low may be a sign of anemia [lack of oxygen-rich blood which can cause fatigue, weakness, and dizziness]) on 1/23/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan for one of five sampled residents (Resident 32) reviewed for unnecessary medications by failing: 1. To revise (update) Resident 32's care plan on the use of bupropion (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]) after the physician increased the dose of the medication on 12/19/2024. 2. To ensure care plans reflect the updated interventions provided to Resident 32. These deficient practices had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 67) reviewed for nutrition care area was provided with the care and services to maintain good nutrition by failing to provide Resident 67 with assistance with all meals as the physician has ordered. This deficient practice had the potential for Resident 67 to lose weight and/or be malnourished (not getting enough of the right nutrients from food).

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two residents (Resident 50) reviewed for Change of Condition (COC) care area received treatment and care in accordance with professional standards of practice when a Situational, Background, Assessment, and Recommendation (SBAR-a structured way to share information between people, especially in healthcare setting) was not created for Resident 50 when the resident had a COC of low iron laboratory results (too low may be a sign of anemia [lack of oxygen-rich blood which can cause fatigue, weakness, and dizziness]) on 1/23/2025. This deficient practice had the potential for Resident 50 to go unmonitored for low iron resulting in the potential for fatigue, weakness, and dizziness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide acceptable parameter of nutrition for one of two sampled residents (Resident 67) reviewed under nutrition when: 1. Resident 67's medical doctor (MD) was not informed when the resident ate less than 50% for two consecutive meals on: - 2/10/2025 for lunch and dinner - 2/13/2025 for lunch and dinner - 2/14/2025 refused breakfast and has less than 50% of lunch 2. Resident 67 was not provided assistance with meals on: - 2/15/2025 dinner and - 2/16/2025 breakfast and lunch . These deficient practices had the potential for Resident 67 to lose weight and/or be malnourished (not enough of the right nutrients from food).

Inspectors wroteBased on interview and record review, the facility failed to provide necessary behavioral health care and services for one of five sampled residents (Resident 78) when the facility failed to conduct a behavioral interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) meeting on the use of Seroquel (an antipsychotic medication used to treat several kinds of mental health conditions) and escitalopram (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]). This deficient practice had the potential to negatively affect the delivery of services.

Inspectors wroteBased on interview and record review, the facility: 1. Failed to act upon the recommendations of the consultant pharmacist for one of five sampled residents (Resident 20) reviewed for Unnecessary Medications, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medications, and Medication Regimen Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) care area by failing to follow-up with Resident 20's physician regarding the consultant pharmacist's MRR recommendation for a thyroid stimulating hormone (TSH- a blood test that measures this hormone) blood draw due to the resident's use of amiodarone (medication used to treat life-threatening heart rhythm problems). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained for one of five sampled residents (Resident 32) when Resident 32's bupropion (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]) dosage was increased. This deficient practice had the potential to place the residents at risk for receiving unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% - unit of measurement) when two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting two of four residents observed for medication administration (Residents 58 and 2) by: 1. Failing to ensure Licensed Vocational Nurse (LVN) 3 administered Resident 58's potassium chloride (medication used in the management and treatment of hypokalemia [low potassium level in the blood]) with a full glass of water as per physician's order. 2. Failing to ensure LVN 6 clarified Resident 2's heparin (an anticoagulant medication used to prevent and treat blood clots) order before medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of one of three sampled residents (Resident 38) reviewed under the kitchen care area. This deficient practice had the potential to result in decreased food and nutrient intake which may result in unintended (not planned) weight loss.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate and complete medical records for one of four sampled residents (Resident 20). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided consistently for one of one sampled resident (Resident 39) reviewed for hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to ensure there was documented evidence that the resident and/or resident representative was involved during the initial interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meeting for admission to discuss the hospice plan of care. This deficient practice had the potential to negatively affect Resident 39's physical comfort and psychosocial well-being resulting in the delay or lack of necessary hospice care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 20) was monitored for the use of vancomycin (medication used to treat infection). This deficient practice had the potential to result in Resident 20's unidentified side effects (an unwanted or unexpected result of a drug) of vancomycin use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one (1) of three (3) sampled residents (Resident 32) reviewed under the Environmental Task when Resident 32's bed controller (device used to change the height and angle of the bed) cable was observed with chipped part at the base with the crews exposed. This deficient practice had the potential to place Resident 32 at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to report allegation of staff-to-resident abuse within two hours to the State Survey Agency (SSA) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), as per its policies on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse.

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 not following the physician's orders. This deficient practice had the potential to result in Resident 1 receiving too much pain medication causing overdose (happens when a toxic amount of a drug, or combination of drugs overwhelms the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received services with reasonable accommodation of the resident needs for two of three sampled residents (Residents 2 and Resident 3). Resident 2 and Resident 3, who were at risk for falls, did not have the call light (an alerting device for residents to call for assistance) within the resident ' s reach. This deficient practice had the potential for not meeting Residents 2 and 3's needs for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of the three sampled residents (Resident 1) by failing to: 1. Provide Resident 1 with fall mats (a soft, cushioned pad placed on the floor, designed to help absorb the impact of a fall and minimize injuries) on both sides of the resident ' s bed. 2. Ensure Resident 1 ' s risk for falls was communicated to the facility staff. The list of fall risk residents on the huddle report (a short meeting held to allow everyone on the team to know specific important information about patients) documents was inconsistent. This deficient practice had the potential to cause falls with injury or harm to Resident 1 and other residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the requested medical records for one of three sampled residents (Resident 1) when a request for medical records was received on 10/24/2024. This deficient practice resulted to Resident 1's right to obtain a copy of the medical records to be violated.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life for one of three sampled residents (Resident 1) when the transportation attendant stated to Resident 1 You shut up! This deficient practice had the potential to result in emotional distress and loss of dignity for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan a person-centered care plan with measurable objectives and timeframes to one out of three sampled residents (Resident 1) by failing to develop a care plan that addressed Resident 4's non compliance with the diet ordered by the physician. Resident 1 was ordering and buying food outside of the facility. This deficient practice had the potential to negatively impact Resident 4's over all health.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician ' s order for out on pass (leave the facility for a period of time and then come back to continue their treatment. Out on pass is requested by the patients or residents and signed by the treating team. It is granted to the patient after clinical assessment) before Resident 1 was allowed to go out of the facility unsupervised. This deficient practice had the potential to place Resident 1 at risk for injuries resulting from accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) by failing to ensure Transporter 2 wore facemask while picking up Resident 3 for an appointment on 8/19/2024, when the facility had one staff who tested positive Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) on 8/17/2024. This deficient practice had the potential for spread COVID-19 among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for two of four sampled residents (Resident 2 and Resident 3) by failing to: 1. Ensure Resident 2 and Resident 3's oxygen tubings were dated when it was changed. 2. Ensure Resident 2's oxygen tubing was free from kinks. These deficient practices had the potential for the residents to receive less oxygen needed in the body and develop respiratory diseases or infections.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (AHA, a non-profit organization that aims to reduce disability and death from cardiovascular diseases and stroke) CPR certification for three of five sampled employees (Registered Nurse 1 [RN 1], Treatment Nurse 1 [TX 1], and Certified Nursing Assistant [CNA 1]) investigated during review of sufficient and competent nurse staffing task. [...]

Inspectors wroteBased on interview and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure injury (PI - breakdown of skin integrity due to pressure) for two out of two sampled residents (Residents 22 and 76) investigated under pressure ulcer care area, by: 1. Failing to ensure Resident 22's low air loss mattress (LALM - mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set according to the manufacturer's guideline. 2. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency (the ability to do something successfully) skills as followed: a. Two (2) of 2 staff were not able to verbalize dishwashing machine temperatures, dishwashing procedures and were not able to follow manufacturer's guidelines for testing dishmachine chlorine solution (used as bleach and disinfectant) concentration with the use of the test strips. b. Two (2) of 2 staff were not following the test strip manufacturer's guidelines when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 41 of 98 residents on Soft Mechanical diet (diet that contains chopped foods that are half an inch or less) and ten (10) of 98 residents on puree diet (diet that contains soft pudding like consistency of food) by: a. Not following standardized recipes for puree green beans, puree pasta and puree bread. b. Not chopping the Italian green beans for Soft Mechanical Diet. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food intake resulting to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. This deficient practice had a potential to cause unplanned weight loss, a consequence of poor food intake to 52 of 98 facility residents who are on regular (no diet restrictions) and puree diet (food with smooth pudding like consistency) consistencies, 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: a. Broken sugar container in the dry storage area. b. Dust build-up on the canned foods and oatmeal debris on storage shelves and dirty floors in the dry storage area. c. Two (2) regular penne pasta and wheat penne pasta was not labeled and dated. d. Clean chopping boards and breads were not protected from dirt splash from an open trash container. e. Forty five of 81 resident's trays had tape residues and 9 trays were cracked and chipped. f. Soiled gloves on the chopping board while the cook was preparing chopped salad. g. Domes and dishes were not air-dried before storing. h. [NAME] was wearing gold bracelet and wristwatch. i. Expired chlorine test strips. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan to address the resident's medical and physical needs for one of two sampled residents reviewed under non-pressure skin conditions (Resident 6) when the facility failed to develop a plan of care for Resident 6's scabs (dry, brown crust formed over a cut or broken skin to stop bleeding and protect the tissue underneath) on the head. This deficient practice had the potential for the resident's scabs to be left untreated and placed the resident at risk for infection.

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 40) investigated during review of unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of two sampled residents reviewed under non-pressure skin conditions (Resident 6) when the facility failed to assess and treat Resident 6's scabs (dry, brown crust formed over a cut or broken skin to stop bleeding and protect the tissue underneath) on the head. This deficient practice had the potential for the resident's scabs to be left untreated and place the resident at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure urinary catheter bags (container that connects to a urinary catheter and collects urine) are not touching the floor for one out of one sampled resident (Resident 83) investigated during review of urinary catheters (a tube that is inserted into the bladder, allowing urine to drain) care area. This deficient practice had the increased potential for residents to obtain a ueinary tract infection (UTI, common infections that happen when bacteria infect the urinary tract).

Inspectors wroteBased on interview, and record review, the facility failed to ensure two (2) out of 2 Treatment Nurses (TX - licensed nurses responsible for providing primary skin care to residents, with an emphasis on treatment and therapy of skin disorders) (Treatment Nurse 1/TX 1, and Treatment Nurse 2/TX 2) have the specific competency and skills set necessary to care for residents with pressure injuries or wounds investigated under the sufficient and competent nurse staffing task by failing to: 1. Identify and address the change in condition when Resident 76's PI measurement increased in size and had a change in characteristics. 2. Ensure accurate documentation of Resident 76's PI measurement, characteristics, and classification. These deficient practices placed the residents at risk for development and worsening of pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Resident 193 in one of two inspected medication carts (Station 2 Cart 4.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and that Resident 193 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the consultant pharmacist's request for an iron panel (a laboratory test showing a resident's blood iron levels) lab draw after resident refusal or notify the physician of resident refusal of the lab draw in one of five sampled residents (Resident 38.) The deficient practices of failing to notify the physician of a resident refusal for lab draw and failing to follow up on the consultant pharmacist's request to obtain lab values increased the risk that Resident 38 could have experience toxicity from too much iron resulting in health complications and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 40) investigated under unnecessary medications. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

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 76) investigated during review of hospice services by failing to provide documented evidence that an interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meeting was held with hospice representatives to discuss Resident 76's hospice plan of care. This deficient practice 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.