Vasona Creek Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP, an individual who controls, manages, and directs the care received by the resident in the facility) in a timely manner for one of three sampled residents (Resident 2) when the resident had a change in skin condition. This failure resulted in a delay concerning the RP's involvement in the provision of care for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychiatric consultation (psych consult, an evaluation conducted by a psychiatrist or psychologist to assess a person's mental health) was completed as ordered for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to identify Resident 1's mental health needs and implement interventions for it.

Inspectors wroteBased on observation, interview, and document review, facility staff failed to refrain from using an alarmed emergency door during non-emergencies. This failure had the potential to compromise the facility's ability to maintain comfortable sound levels for the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the environment was as free of accident hazards as possible when the alarm to an emergency door was turned off. This failure had the potential to allow residents to exit the facility undetected and without permission.

Inspectors wroteBased on interview and record review, the facility failed to follow its own policies and procedures to ensure social services carried out physician orders for referrals for one of three sampled residents (Resident 1). This failure resulted in referral delays for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of three residents (Resident 1) when the facility failed to follow up Resident 1's physician orders for Psychiatrist and Dermatology consultations, and failure to provide nail care for Resident 1's long fingernails. These failures had the potential to negatively affect the residents' health, safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure physicians orders were carried out or documented as written for one out of four sampled residents (Resident 1), when three doses of intravenous (through the veins) vancomycin (an antibiotic) were not documented on three separate days. This had the potential to compromise the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to carry out and implement a physician ' s order in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to compromise Resident 1 ' s health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure practices that met professional standards of quality and facility policy and procedures (P&P) for one of 3 sampled residents (Resident 1) when: 1. Resident 1 received two insulin (an injectable medication for the treatment of high blood glucose/sugar) orders and was diagnosed with diabetes (disease that impairs the body's ability to regulate blood sugar [BS]) by Physician B without documented evidence of laboratory results and/or symptoms that met the diagnostic criteria for diabetes according to the American Diabetes Association (ADA). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored in 3 of 6 medication carts when: 1. Discontinued medications for 3 residents (Residents 2, 3, and 4) were not removed from active stock; and 2. An insulin pen (a pre-filled pen containing multiple doses of insulin for the treatment of high blood sugar) was not labeled with patient-specific information and not dated with an open date. These failures had the potential for medication errors; spread of infection due to being mixed up with another resident's insulin pen; and insulin given past its effective date.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete medical record for one of three sampled residents (Resident 1) when: 1. The facility treated a wound to Resident 1's coccyx (tailbone) that was present upon admission, but did not document that they obtained a physician's order for wound treatment until eight days after admission; 2. The facility did not document treatments of Resident 1's coccyx wound until eight days after admission; and, 3. There was one week during which the facility did not document the assessment of Resident 1's coccyx wound. These failures had the potential to compromise the facility's ability to ensure Resident 1's wound was treated and monitored.

Inspectors wroteBased on interview and record review the facility failed to follow physician's orders for Resident 1 when Resident 1's physician's steroid tapering (process of slowly decreasing a steroid dosage over time) orders were not carried out correctly. This resulted in Resident 1 receiving a larger dosage than prescribed for six days, and Resident 1 missing one steroid dose entirely. These failures resulted in Resident 1 not receiving proper treatment, and had the potential to compromise Resident 1's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment orders for respiratory [breathing] therapy (RT, treatment that helps individuals optimize their respiratory function, breathe more easily, and live more comfortably) was carried out as ordered for six out of six residents (Residents 3, 5, 6, 7, 8, and 9). The failure had the potential for the residents not attaining their highest practicable physical well-being, such as not being able to attend activities or carry out the activities of daily living (ADLs; such as eating, toileting, dressing, personal hygiene, etc.) due to reduced respiratory functions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate storage of medications in two of four medication rooms when: 1. The medication room that housed the facility's automated dispensing unit (ADU - where medications are stored and electronically tracked) was unlocked when not in use; 2. Two expired medications were identified in the medication refrigerators; and 3. The medication refrigerator temperature in Medication room [ROOM NUMBER] was not consistently monitored twice daily as per the U.S. Centers for Disease Control and Prevention's (CDC) guidelines. The failures had the potential for unauthorized access to dangerous medications; expired medications given to residents; and ineffective medications or loss of drug potency due to unmonitored temperatures.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff immediately reported an incident of suspected abuse to the Administrator for 1 (Resident #32) of 1 resident reviewed for abuse.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to resubmit a new Level I Preadmission Screening and Resident Review (PASARR) for 1 (Resident #74) of 4 residents reviewed for PASARR and failed to ensure a PASARR was accurately completed for 1 (Resident #110) of 4 residents reviewed for PASARR.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain treatment orders for a laceration for 1 (Resident #54) of 2 sampled residents reviewed for non-pressure related alteration in skin integrity.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to follow enhanced barrier precautions (EBP) for 1 (Resident #124) of 5 residents reviewed for wounds. Specifically, during an observation of wound care treatment for a pressure ulcer for Resident #124 staff members failed to wear a gown as part of the appropriate personal protective equipment (PPE).

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 (room [ROOM NUMBER]) of 62 resident rooms accommodated no more than four residents per room.

Inspectors wroteBased on interview, and facility document review, the facility failed to provide the required 80 square (sq) feet (ft) of living space per resident in 16 of 62 resident rooms in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for 13 of 28 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) when there were multiple days for which there was no evidence of documentation that scheduled treatments were provided. This failure had the potential to compromise the residents' health, safety, and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided for three of three sampled residents (Residents 1, 2, and 3) when there were multiple days for which there was no documentation that chest percussion therapy (treatment that involves using cupped hands to tap the area over the resident's lungs to help clear secretions) was provided as ordered. This had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP, person designated to make decisions on behalf of the resident) of a change of condition and new medication order for one of three sampled residents (Resident 1). This failure had the potential to compromise the RP's right to be fully informed of the resident's health condition and treatment.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1). Failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to accurately document in the clinical record for one of three sampled residents (Resident 1) when Resident 1's clinical record contained progress notes pertaining to a different, unknown resident. This failure had the potential to compromise the facility's ability to monitor and implement interventions for the correct resident.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1). Failure to accurately assess had the potential compromise the facility's ability to develop and implement interventions to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of three sampled residents (Residents 1 and 2) when: 1. There was no documentation that the facility completed Skin & Wound Evaluations on a weekly basis for Resident 1; and 2. The facility did not consistently complete the Nursing Weekly Summary (an assessment form) for Residents 1 and 2. These failures had the potential to compromise the facility's ability to identify the residents' needs and implement interventions accordingly.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Elopement Risk Observation/Assessment for two of three sampled residents (Residents 1 and 2). This failure compromised the facility's ability to identify residents who were at risk for elopement and to implement relevant interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman (resident advocate) office was notified of a hospital transfer for one of four sampled residents (Resident 2). This failure had the potential to result in Resident 2 not having someone to advocate for his admission, transfer, and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sample residents (Resident 1) received medication as ordered. This failure had the potential to compromise the resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with Standing Orders for one of four sampled residents (Resident 1). This failure had the potential to compromise the resident's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures when: 1. Staff did not properly wear face masks in resident care areas; and 2. The facility did not ensure a family member of one of three sampled residents (Resident 1) was screened for Coronavirus Disease 2019 (a contagious respiratory illness caused by a virus) prior to entering the facility. These failures had the potential to result in the spread of infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. Licensed nurses did not administer a medication because it was not available in the facility; 2. The facility did not receive lab results (blood test results) and did not follow up with the lab regarding these results; 3. The facility did not administer Boost High Protein (a nutritional drink) as indicated in the admission orders; 4. Licensed nurses did not carry out an admission order for Pedialyte (a solution used to replace fluids and minerals in the body) until five days after admission; 5. The facility did not update wound treatments as ordered; and 6. There was no documentation that the facility completed a nutritional risk assessment upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to fulfill a records request made by the responsible party (RP, person designated to make decisions on behalf of a resident) for one of three sampled residents (Resident 1). This failure compromised the resident's and/or RP's right to access personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to report a potential suspicion of a crime to the California Department of Public Health (CDPH) within 24 hours for one of three sampled residents (Resident 1). This failure had the potential to jeopardize the protection, health, and safety of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans to address communication and visual impairment for one of three sampled residents (Resident 1). This failure had the potential to result in the resident not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practice was implemented for one of three sampled residents (Resident 1) when Resident 1 ' s gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply nutrition or liquid when residents are unable to take anything by mouth) feeding syringe was undated. This failure could result in the spread of infection and cross-contamination in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for two of three sampled residents (Residents 1 and 2) when: 1. For Residents 1 and 2, there were multiple days for which there was no documentation that scheduled treatments were provided; 2. For Resident 1, documentation indicated licensed nurses did not administer medications in a timely manner on multiple days; 3. For Resident 1, licensed nurses did not administer certain medications because they were not available in the facility, and there was no documentation that the licensed nurses notified Resident 1 ' s physician about the missed doses; and 4. For Resident 2, there was no documentation that staff monitored the resident after a room change as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain temperatures in accordance with their policy for two out of three resident rooms (Rooms B and C). This failure had the potential to compromise the residents ' comfort and well-being.

Inspectors wroteBased on interview and record review the facility failed to meet professional standards of care for one of three sampled residents who fell (Resident 1). Resident 1 ' s post fall documentation lacked an assessment to determine potential cause(s). This failure led to a missed opportunity of identifying pertinent preventative measures and placed the resident at risk for further falls.

Inspectors wroteBased on interview and record review the facility failed to follow standards of care for when a physician's order was not followed for one of two sampled residents (Resident 1). Resident 1's physician order to notify family member of refusing to take medications was not consistently followed. This failure resulted in missed opportunities for the family to be actively involved in the resident ' s care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a discharge plan of care to include the resident and or family participation, preferences and needs to optimally prepare and transition him to a new home living environment for one of five sampled residents (Resident 3). This failure placed Resident 3 at risk for unsafe discharge with the potential to result in health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent documentation for one of three sampled residents (Resident 1) when: 1. There were two different versions of the same Post-Discharge Plan of Care; and 2. There were two different versions of the same Inventory of Personal Effects. These failures resulted in an inaccurate presentation of information.

Inspectors wroteBased on interview and record review the facility failed to ensure communication with the dialysis facility was properly coordinated when dialysis communication records (DCR) for one of two (Resident 2) was not completed. This failure may affect the quality of dialysis care being provided to the resident.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of a resident physical altercation of one of three sampled incidents (Resident 1). This failure had the potential of reaching an inaccurate conclusion of what had occurred.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase their range of motion and/or to prevent further decrease in range of motion for one of three sampled residents (Resident 1) when Resident 1 did not receive RNA (Restorative Nursing Assistant) treatment as ordered and as care planned. This failure had the potential to negatively affect Resident 1 ' s health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative nursing assistant (RNA) services as ordered for one of three residents (Resident 1). This failure had the potential to result in decreased mobility and health complications in the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences (meetings held to discuss the plan of care with the resident or representative) were conducted for one of three sampled residents (Resident 1). This failure had the potential to compromise the resident's or representative's right to participate in the care planning process.

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. There was no documentation that the facility regularly applied Resident 1's neck collar (device used to immobilize the neck) as recommended by a physician; 2. The facility did not develop a care plan to address an injury to Resident 1's neck; and 3. There was no documentation that the facility conducted an investigation regarding an injury to Resident 1's neck. These failures had the potential to negatively affect the resident's health and well-being.

Inspectors wrote10. During an observation on 11/18/2021 at 9:00 a.m., treatment nurse B (TN B) performed wound treatments on Resident 118's feet. While wearing gloves, TN B cut the old bandages off Resident 118's feet with a pair of scissors. He removed his gloves and put on a new pair. TN B then cleaned the wounds on Resident 118's feet. He removed his gloves and put on a new pair. TN B then applied Betadine (topical medication) to the wounds on Resident 118's feet. He removed his gloves and put on a new pair. TN B then applied Santyl (topical medication) to the wound on Resident 118's right foot and covered the foot with dry dressings. He removed his gloves and put on a new pair. TN B then applied Santyl to the wounds on Resident 118's left foot and covered the foot with dry dressings. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a functioning, habitable, comfortable and homelike environment for five of 30 sampled residents (Residents 111, 106, 11, 85 and 48) when: 1. For Resident 111, the string for the over bed light was short and the facility used a bath towel to make it longer; 2. For Resident 106, the string for the over bed light was short and the facility used a face cloth to make it longer; and 3. For Residents 11, 85 and 48, the facility did not maintain comfortable temperatures. These failures had the potential to compromise the residents' health, safety and comfort levels in the facility.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 9.43% when five medication errors occurred out of fifty-three opportunities during medication administration for four out of nine residents (Residents 380, 19, 79 and 108). These deficient practices resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effects of the medications and may cause preventable side effects for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. The microwave film was peeling off and had a yellowish color; 2. The preparation table drawer was broken; 3. There was a build up of icicles in the kitchen freezer; 4. Two dented cans and one compromised tomato juice were found in the dry storage; 5. Dishwasher liquid was stored near the dry goods; 6. Two ice machines had whitish to yellowish substances; 7. Vegetable peeler had a paper label and had a greenish color; 8. The food strainer was broken; 9. Three cutting boards had a deep cut; 10. Staff did not demonstrate the proper procedure for testing the strength of sanitizer used for sanitizing food contact surfaces. [...]

Inspectors wroteBased on observation, interview and record review, the facility's staff failed to ensure dignity and respect were maintained for two of 30 sampled residents (Residents 30 and 380). This deficient practice resulted in residents feeling sad, anxious and had the potential to affect Residents 30 and 380's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to complete the admission Minimum Data Set (MDS, an assessment tool) within 14 calendar days after admission for one of 30 sampled residents (Resident 375). This deficient practice had the potential to delay care planning and delivery for Resident 375's care areas that would have been identified in the admission MDS.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 30 sampled residents (Residents 20 and 73). Failure to accurately assess the residents had the potential to compromise the facility's ability to provide resident-centered care planning and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for three of 30 sampled residents (Residents 9, 59 and 118) when: 1. For Resident 9, the facility did not develop a care plan to address the presence of a pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin); 2. For Resident 59, the facility failed to develop a care plan to address the management of Resident 59's impaired vision; and 3. For Resident 118, the facility did not develop a care plan to address the use of an anticoagulant (medication that thins the blood and increases the risk for bleeding). These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for two of 30 sampled residents (Residents 58 and 17) when: 1. For Resident 58, staff did not apply a foot cradle (device intended to prevent sheets and blankets from touching the feet) as ordered by the physician; 2. For Resident 17, staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis services consistent with professional standards and to ensure staff coordinated resident care with the dialysis facility for two of 30 sampled residents (Residents 111 and 17) who received dialysis (medical procedure to remove fluid and waste products from the blood) when: 1. Dialysis communication records (DCRs) were not completed and; 2. Dialysis care plans were not resident-centered. These failures had the potential to affect the quality of dialysis care being provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided accurately, timely and as ordered for three residents (Residents 79 and 108) when medications ordered by the physician were not available in the medication cart for administration to Residents 79 and 108 and These deficient practices resulted in the residents not receiving their ordered medications and had the potential for misuse or diversion of controlled medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 30 sampled residents (Resident 60, 73 and 20) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior when: 1. For Resident 60, there was no evidence of non-pharmacological interventions for a new behavior; 2. For Resident 73, no care plan was developed for the use of benztropine (an anti-tremor medication used to treat side effects of other drugs), no specific manifestation of extrapyramidal symptoms (EPS, drug-induced movement disorders, dystonia [involuntary muscle contractions], akathisia [urge to move], tardive dyskinesia [repetitive involuntary movements]) being monitored, and orthostatic hypotension was not monitored; and 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Two expired medications were not properly discarded and not stored in the medication cart and, 2. Two medications were not properly labeled after being opened. These deficient practices had the potential for unsafe and ineffective use of medications being used past the expiration date and risk the misuse of medications because they were unlabeled or improperly labeled.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs], for antibiotic use protocol (official procedure or system of rules) with a systematic approach of monitoring and evaluating for the appropriate use of antibiotics to improve resident health outcomes and reduce antibiotic resistance (bacteria not controlled or killed by antibiotics) for three of 30 sampled residents (Residents 60, 105 and 59). This failure had the potential for inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to notify residents' representatives and families of a confirmed COVID-19 (a respiratory disease caused by a virus which can result in severe illness and death) test by 5:00 p.m. the next calendar day when Resident 282 received a positive COVID-19 test result on 10/16/21 and notifications were not sent out until 10/18/21. This failure resulted in residents' representatives and families not receiving timely notification regarding the status and impact of COVID-19 in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure one of 62 resident rooms (room [ROOM NUMBER]) accommodated no more than four residents. Having more than four residents per room had the potential to compromise the quality of life and quality of care the residents received.

Inspectors wroteBased on observation and interview, the facility failed to provide at least 80 square feet per resident for 16 of 62 resident rooms. This failure had the potential to compromise the quality of life and the quality of care the residents received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary condition was maintained when there was no air gap (a gap of air between the floor and a drain pipe) in one of two facility ice machines. This failure had the potential to cause foodborne illness to residents. During an inspection and concurrent interview with the maintenance director (MD), the ice machine's water drain pipe and outlet hose were in the floor sink below the floor level rim (a type of floor drain used as an indirect waste receptor). The MD acknowledged the outlet hose and drain pipe should be above floor level to create an air gap and to avoid ice contamination in the event of an accidental back flow. He also stated the pipe and the hose could have been dislodged when the housekeeper was cleaning the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to observe residents' rights on personal privacy for two of four residents (48 and 246) when: 1. Licensed vocational nurse G (LVN G) did not provide privacy for Resident 48 during the administration of fluids via gastrostomy tube (GT, a surgical opening into the stomach for administration of liquids nutrition and medication). 2. Resident 246's private body part to be partially exposed for anyone passing by to see. These failures had the potential to affect residents' self-worth and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive plan of care for two of thirty residents (Resident 67 and Resident 82) when: 1. Resident 67's post fall care plan interventions were not re-evaluated. 2. Resident 82's unsafe behavior of wandering into other residents' rooms was not care planned These deficient practices placed residents at risk for potential injuries and accidents.

Inspectors wroteBased on observation and interview, the facility failed to provide appropriate positioning for eating for two of twenty residents (204 and 205). This failure had the potential to contribute to the risk of aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise one of three residents (Resident 82) when Resident 82's behavior of wandering into other resident rooms was not monitored. This deficient practice placed residents at risk for unsafe conditions.

Inspectors wroteBased on interview and record review, the facility failed to monitor a stage one pressure ulcer for one of six sampled residents (Resident 402) when Resident 402's weekly wound assessment was not completed. This failure had the potential to delay treatments and lead to worsening pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to get a physician's order and document administration and resident response for oxygen (a colorless and odorless gas that people need to breathe) therapy for one of three residents (Resident 209) when Resident 209 was administered oxygen without a physician's order. These failures had the potential to result in ineffective oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medication for one of five residents (Resident 22) when one routine medication was not available during the 9 a.m. medication pass. This failure had the potential to cause delay in treatment and compromise resident's health.

Inspectors wroteBased on interview and record review, the facility failed ensure that residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) for three of 10 sampled residents (18, 20, and 31) when: 1. For Resident 18, lipid panel (level of fats in the blood) and hemoglobin A1C (level of sugar in the blood) blood levels were not done for the used of Quetiapine (drug used to help improve behaviors). 2. For Resident 31, no evidence of documentation that non-pharmacological interventions were tried/attempted first before giving PRN (as needed) Ativan tablets (medication for anxious behaviors). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure medication cart and ensure safe handling of discontinued medications in two of three medication carts when: 1. Medication cart 3A was left unlocked and unattended. 2. Medication cart 1B had discontinued prescription medications. These failures had the potential for unauthorized access and accidental administration of discontinued medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure documentation was complete for two of fourteen residents (Residents 204 and 47), when: 1. Resident 204 was administered insulin (a medication for high blood sugar) and the dosage was not documented; 2. Resident 47 had no documentation regarding the application of carrot device (a device used to support, prevent, or correct deformities of the hand) on the right hand by CNA on a daily basis. These failures had the potential to negatively affect the delivery of care and services to the residents due to incomplete medical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an infection control measures for two of 30 sampled residents (1 and 18) when: 1. Resident 18's humidifier (a device for increasing or controlling the water vapor) tubing was undated and tracheal mask (a mask made of plastic used to protect the artificial created opening in the neck which the person breathes) was exposed. 2. Resident 1's urinary catheter (a tube inserted into a patient's bladder to allow the patient's urine to drain freely from the bladder) tubing was touching and dragging on the floor while Resident 1 was using the wheelchair. These failures had the potential for the development and the spread of infections in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of 62 resident rooms (509) accommodated no more than four residents per room. This failure had the potential to compromise the quality of life and the quality of care the residents received.

Inspectors wroteBased on observation and interview, the facility failed to provid at least 80 square feet per resident for 16 of 62 resident rooms. This failure had the potential to compromise the quality of life and the quality of care the residents received.