Vernon Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of four sampled residents remained separated after a resident-to-resident altercation on 7/12/2026. This failure resulted in Resident 2 entering Resident 1's room on 7/16/2026 and placed Resident 1 at risk for abuse and injuries.

Inspectors wroteBased on interview, and record review the facility failed to follow its Policy and Procedure (P&P) titled, Abuse Prevention and Management which indicated the Administrator or designated representative will report all allegations of abuse to the California Department of Public Health (CDPH) Licensing and Certification within two hours, for one of four sampled residents (Resident 2), when Resident 1 allegedly threw a lotion bottle at Resident 2 on 7/12/2026. This deficient practice delayed the investigation by the CDPH and placed Resident 2 at risk for further abuse and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was revised for two out of four sampled residents (Resident 1 and 2) after Residents 1 and 2 had an altercation on 7/12/2026. This deficient practice had the potential for Resident 1 and 2 to be involved in another altercation. Findingsa. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable worry that interferes with daily functioning), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure an individualized care plan was developed and implemented for one of three sampled residents (Resident 2), whose discharge was delayed. This deficient practice resulted in the resident's delayed discharge and had the potential to affect the resident's psychosocial and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement the Care Plan for one of three sampled residents (Resident 1) titled, [Resident 1] exhibits increased agitation, verbal aggression toward nursing staff, and refusal of prescribed medications which indicated nurses would notify the physician when Resident 1 refused prescribed medications. This deficient practice had the potential to result in delayed care and services for Resident 1, and worsening of the resident's condition and behaviors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse by failing to protect Resident 1 from a physically aggressive resident (Resident 2), when Resident 2 physically abused Resident 1. This deficient practice resulted in Resident 1 being physically abused by Resident 2. Resident 1 sustained right eye injury after being struck in the face, requiring emergency transfer to a General Acute Care Hospital (GACH). Resident 1 underwent emergency surgical repair (an operative procedure to treat traumatic damage to the eye and surrounding structures, preserve vision, restore the eye's anatomy and function, relieve pressure, and promote healing) of the right eye and remained hospitalized from [DATE] through 7/1/2026.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse Prevention and Management which indicated the Administrator (ADM) or designated representative will report all injuries of unknown origin to the California Department of Public Health (CDPH) Licensing and Certification within two hours, for one of three sampled residents (Resident 1), when Resident 1 sustained nasal (nose) fractures (broken bone), frontal scalp hematoma (collection of blood that forms in the tissue caused by a broken blood vessel that could be due to trauma or injury) and a laceration (cut or tear in the skin) to the Resident's left eyebrow on 6/9/2026. This failure had the potential to delay the investigation by the CDPH and placed Resident 1 at risk for continued abuse, neglect and injuries.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin for one of three sampled residents (Resident 1) when Resident 1 sustained nasal (nose) fractures (broken bone), frontal scalp hematoma (collection of blood that forms in the tissue caused by a broken blood vessel that could be due to trauma or injury) and a laceration (cut or tear in the skin) to the Resident's left eyebrow on 6/9/2026. This failure had the potential to result in unidentified abuse and neglect towards Resident 1 and could negatively affect the Resident's well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement Resident 1's Care Plan titled, (Resident 1) was at risk for unsafe behaviors and impaired safety awareness related to schizophrenia (a mental illness that is characterized by disturbances in thought), encephalopathy (disease or damage that affects the brain), cognitive (ability to think and reason) impairment, akathisia (movement disorder) and behavioral disturbances as evidenced by agitation, restlessness, confusion, poor judgment.and ongoing need for 1:1(one to one, when one staff member is assigned to directly monitor no more than one resident. The staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons) monitoring for safety, which indicated the facility will maintain 1: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a resident's refusal to take their scheduled medications for one of four sampled residents (Resident 2). This deficient practice had the potential for Resident 2 to decline and resulted in delayed necessary care and medical interventions due to the physician not being notified in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for right ear pain for one of one sampled resident (Resident 1). This deficient practice had the potential to result in a lack meeting necessary care and addressing medical needs for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to monitor two of four sampled residents (Residents 1 and 3) behaviors while prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). This deficient practice had the potential to result in the administration of unnecessary psychotropic medication that could cause harm to Residents 1 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the dignity of one of five sampled residents (Resident 5) when Resident 5 walked in the hallway wearing a diaper. This failure had the potential to result in Resident 5 feeling embarrassed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse- Reporting and Investigations which indicated the facility will report injuries of unknown source (bodily harm that cannot be explained) to the California Department of Public Health (CDPH) within two hours, for one of four sampled residents (Resident 1) when Resident 1 was found with a wound to her right forearm on 4/30/2026. This failure had the potential to result in a delay in the investigation by the CDPH and placed Resident 1 at risk for neglect and abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin (bodily harm that cannot be explained) for one of four sampled residents (Resident) 1, when Resident 1 was found with a wound to her right forearm on 4/30/2026. This failure had the potential to result in unidentified abuse and placed Resident 1 at risk for continued abuse and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure an altercation between two of four sample residents (Resident 3 and Resident 4) was reported to the California Department of Public Health (CDPH) when Resident 4 hit and threw coffee at Resident 3's face. This deficient practice of not reporting the altercation to the CDPH within two hours delayed the investigation and placed Resident 3 at risk for further injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 was within three to five feet ([ft.] - unit of length) for one sample resident (Resident 2) who was placed on one-to-one (1:1, close supervision) monitoring. This deficient practice of CNA 2 not standing three to five feet of Resident 2 had the potential for the resident to have another altercation.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure a Change of condition ([COC] -a significant deviation from a patient baseline condition that requires immediate assessment and intervention to prevent further decline) form was initiated for Resident 3 with a skin rash (an area of irritation, inflamed, or damaged skin). 2. Provide treatment for Resident 3's skin rash. 3. Give a complete assessment report to General Acute Care Hospital ([GACH] -a hospital 24-hour medical services) regarding Resident 3's skin rash prior to admission. This deficient practice of not reporting, treating, or monitoring Resident 3's skin rash resulted in a diagnosis with scabies (highly contagious skin infestation). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure:1. One expired large can of cherry fruit filling, in the dry storage room was disposed. 2. Four cereal bowls on the shelf in dry storage were not dated.3. The refrigerator (reach in) had containers of applesauce, juice, and jelly without use by date (the last day a manufacturer recommends consuming a product for peak quality and safety).4. The Dietary Aide (DA) 1 had touched the cleaned dishes after touching dirty dishes without removing gloves and washing her hands. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 87 out of 93 residents who received food from the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 82) Certified Nursing Assistant (CNA) 1 was seated while feeding Resident 82. This deficient practice of CNA 1 not seated while feeding Resident 82 had the potential to cause him to feel uncomfortable. During a review of Resident 82's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 82's diagnoses dysphagia (difficulty swallowing), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and aphasia (a disorder that makes it difficult to speak). [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure beneficiary notices were accurately completed for two of two sampled residents (Resident 21 and Resident 109). This deficient practice had the potential to result in residents and/or their responsible parties not being notified of their payment options (Option 1-Resident will pay but can appeal insurance, Option 2- Resident will pay and cannot appeal insurance, Option 3- Resident no longer wants care or services provided) after Medicare Part A benefits expired.

Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Ensure a Complete Blood Count (CBC- a routine blood test that measures and evaluates your red blood cells, white blood cells, and platelets) and Comprehensive Metabolic Panel (CMP- a blood test checking organ function and chemical balance) labs were obtained for one of six sampled residents (Resident 4). This deficient practice had the potential to result in fluid and electrolyte imbalances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2) Activities of Daily Living ([ADL] -routine task/activities such as bathing, dressing and toileting a person performs daily to care for themselves) was provided personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving). This deficient practice of not maintaining standards of practice had the potential to compromise Resident 2's personal hygiene. During a review of Resident 2's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to: 1. Ensure a low air loss mattress (a mattress designed to prevent and treat pressure wounds) setting was correct for one of six sampled residents (Resident 3). This deficient practice had the potential to result in further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly remove expired items and failed to organize stored items in the medication storage room. This failure had the potential to result in staff using expired items for specimen collection and a delay of care for residents while searching for necessary care items. During an observation on [DATE] at 12:33 p.m., in the medication storage room, the following was observed:One open bottle of baby oil in the far-right upper cabinet,Two containers of air freshener, a used face mask, one BD Safety Glide 1mL syringe, and multiple specimen bags were in drawer 1, labeled elastic bandage rollsTwo expired Aptima urine specimen collection kits dated [DATE], (6) 4 mL expired vacutainers, and (1) expired HOLOGIC Aptima 2cc urine specimen container dated [DATE], in the second drawer 2 to the left. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of six sampled residents (Resident 2) recommendations for laboratory services were not completed. This deficient practice of not following up with the Medication Regimen Review ([MRR] - a medication list that is reviewed to ensure safety and effectiveness, eliminate unnecessary drugs) recommendations had the potential to cause a delay in emergency medical care and treatment. During a review of Resident 2's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility Licensed Nurse 1(LVN1) failed to perform hand hygiene (cleansing hands with soap or an alcohol-based rub), at the door of room [ROOM NUMBER], prior to touching medication cups during preparation for medication administration. This failure had the potential for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and risk to exposure of residents to infectious organisms (germs). During an observation on 1/8/2026 at 7:47 a.m., at medication cart #1, LVN1 failed to perform hand hygiene before preparing medication cups for medication administration (the action of dispensing, giving, or applying something) .During an interview on 1/8/2026 at 7:50 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Provide at least 80 square feet (sq. ft.- a unit of measurement) per resident for 31 out of 34 resident bedrooms. This deficient practice had the potential to result in inadequate nursing care and safety issues for the residents.

Inspectors wroteBased on interview and record review, the facility failed to document a change of condition (COC) assessment for one of six sampled Residents (Resident 6) when Resident 6 refused psychotropic medications. This deficient practice had the potential to result in Resident 6 not receiving proper monitoring and treatment for behavior changes and placed Resident 6 at risk for hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a person-centered care plan was developed for one of six residents (Resident 6) who had been refusing to take medications. This failure had the potential for poor communication and result in the resident not receiving the necessary care and services to maintain its highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to: 1). Ensure three (3) of six (6) sampled residents' (Residents 1, 4, and 6) medications were administered timely. This failure resulted in delayed interventions and had the potential to exacerbate (worsen) the residents' conditionand can cause resident transfer to the general acute care hospital. 2). Ensure the Controlled Drugs-Count Record (Narcotic [medications that are regulated by law due to their potential for misuse or harm] count sheet), for two (2) of 3 medication carts at the facility, were completely filled-up. This deficient practice had the potential for loss of accountability, drug diversion, or theft.

Inspectors wroteBased on interview and record review, the facility failed to:1 1. Ensure one of three sampled residents (Resident 1) who was transferred to a General Acute Care Hospital (GACH) on 8/15/2025 due to altered mental status ([AMS] - a significant change in a person's awareness, consciousness, and cognitive function, such as confusion, disorientation, drowsiness, or unresponsiveness) was readmitted to the facility when the GACH cleared him to return to the facility on 8/29/2025. This deficient practice resulted in Resident 1 remaining in the hospital for 14 days beyond the initial date of discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and document informed consent for the use of psychotropic medications (drugs that affect mental processes and behaviors) for one of two sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for sustaining adverse effects from the medications and removed Resident 1's right to refuse psychotropic medications at a dose or route (e.g. by mouth, by injection, etc.) he did not want.

Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed (PRN) psychoactive medication (drugs that affect brain chemistry and alter a person's mental state, mood, or behavior) order for one of two sampled residents (Resident 1) did not exceed 14 days. This deficient practice placed Resident 1 at risk of sustaining adverse effects related to the prolonged use of psychoactive medication without documented indication.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Interdisciplinary Team (IDT, a group of healthcare professionals from various disciplines who collaborate to provide comprehensive care) meeting, a fall risk evaluation, and a post-fall evaluation were conducted for one of two sampled residents (Resident 1) following a fall. This deficient practice placed Resident 1 at risk for sustaining repeat falls and potential injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]), and history of aggressive behavior, was provided with the necessary behavioral health care in accordance with the comprehensive assessment and care plan. The facility failed to: 1. Ensure an accurate Minimum Data Set (MDS, a comprehensive quarterly resident assessment) to include Resident 1's history of aggressive physical and verbal behavior. 2. Develop effective and individualized care plan interventions for Resident 1's behaviors including supervision, frequency and re-evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was safely discharged to a lower level of care by failing to: 1. Follow its policy and procedure (P&P) titled, Discharge and Transfer of Residents, which indicated the facility may discharge a resident if the services provided by the facility were no longer required, when Resident 1, who required the services provided by the facility was discharged to a Board and Care facility ([B&C] a small residential home that provides lower-level of care and supervision to seniors who need assistance with daily living tasks but do not require 24-hour nursing care). 2. Ensure Resident 1 was safely discharged to B&C 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure titled Fall management Program to conduct and initiate an Interdisciplinary Team (a group of professionals from various disciplines who collaborate to address a patient's needs) meeting post fall for one of four sampled residents (Resident 1) after sustaining three falls. These failures resulted in Resident 1 continuing to fall and had the potential to cause life threatening injuries.

Inspectors wroteBased on interview, and record review, the facility failed to implement treatment orders for skin lesions for one of six sampled residents (Resident 3) by failing to: 1. Ensure physician orders were transcribed (putting data into written or printed form) into Resident 3 ' treatment administration record. 2. Ensure skin treatments were documented when it was performed for Resident 3. These deficient practices had the potential to place Resident 3 at risk of not receiving appropriate skin treatment and a delay in communication between licensed staff due to incomplete medical records.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement its policy and procedure (P&P) titled, Abuse-Prevention, Screening, and Training Program, dated 7/2018, which indicated facility did not condone any form of resident abuse or neglect for one of four sampled residents (Resident 1). 2. Ensure staff followed Resident 2 ' s Care Plan titled, Resident has behavioral problem pacing (the act of walking back and forth) in hallway with increased agitation with intervention a sitter (staff who observes constantly and redirect patient from engaging in a harmful act) and to intervene as necessary to protect the rights and safety of others. This deficient practice resulted in Resident 2 hitting Resident 1 in the face.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Monitor one of five sampled residents (Resident 2) behaviors while prescribed psychotropic medications (medications that can alter brain chemistry, impact body functions, and modify a person thoughts, moods, feelings, awareness, and perceptions). These failure had the potential to result in inconsistent behavior monitoring and placed Resident 2 at risk for not receiving the necessary interventions for increased psychiatric behaviors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure three tomatoes in the walk-in refrigerator did not contain rotten spots 2. Ensure two pitchers of lemonade and powdered lemonade mix was not stored on the sink at the sanitizer/detergent mixing area. 3. Ensure the sight glass tube (transparent area that allows you to check the level of a liquid) on the coffee machine did not contain build up. These deficient practices had the potential to result in food borne illness (sickness from eating food with harmful bacteria) for any resident consuming the tomatoes, residents getting sick from the coffee machine buildup, and illness related to a possible mix up of chemicals with the lemonade.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 298) was free from significant medication errors by failing to administer medications as ordered from 12/1/2024 to 1/9/2025. 1. Two (2) doses of fluvoxamine maleate (used to treat obsessive-compulsive disorder [bothersome thoughts that will not go away and need to perform certain actions over and over] and social anxiety disorder [extreme fear of interacting with others or performing in front of others that interferes with normal life]) 2. Two (2) doses of pantoprazole sodium (treats conditions that cause too much stomach acid) 3. 10 doses of demeclocycline HCL (used to treat infections caused by bacteria) 4. 14 doses of risperidone (used to treat certain mental disorders) 5. Three (3) doses of Vascepa (used to lower high levels of fats in adults). 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the bottom of the drawer on medication cart #3 and a bottle of Pro-Stat liquid (a ready-to-drink concentrated liquid protein medical food) was free from sticky residue. This deficient practice had the potential for dust and other particles to adhere to the sticky residue.

Inspectors wroteBased on observation, interview, and record review, the facility failed: 1. To post the recent survey results by California Department of Public Health ([CDPH] - state licensing and certification agency) in the areas of the facility that are prominent and accessible to the residents, resident representative, family members, and visitors. This deficient practice placed the residents, resident representative, family members, and visitors at risk of not knowing the status of the facility non-compliance outcome results and past performance history.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one out of eight sampled residents (Resident 20) had the trash emptied timely to prevent gnat production. This deficient practice resulted in an unsanitary environment for Resident 20.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Transmit the discharge Minimum Data Set ([MDS] - a resident assessment tool) within 14 days after completion to Center of Medicare and Medicaid Services (CMS) for one of 22 sampled residents (Resident 81). This deficient practice had the potential to result in billing error and inaccurate data on resident care needs.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one out of eight sampled residents (Resident 40 and Resident 49) received a Preadmission Screening and Resident Review ([PASARR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level II evaluation. This deficient practice had the potential to result in Resident 40 not receiving the required mental health care and services.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop an individualized person-centered plan of care with measurable objective, timeframe, and interventions for resident with significant weight loss (5 percent ([%] - unit of measurement) in 1 month for one of three sampled residents (Resident 87). This deficient practice had the potential to place Resident 87 at risk for further weight loss related to not having nutritional interventions.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure one out of three sampled residents (Resident 56) had their weight taken consistently to monitor for weight changes. This deficient practice had the potential for Resident 56 to experience weight gain and weight loss without knowledge of the facility staff and can cause a delay in interventions.

Inspectors wroteBased on interview and record review, the facility failed to provide vision care services to one of one sampled resident (Resident 37) by failing to: 1. Arrange for optometry (the profession of examining the eyesight and prescribing corrective lenses to improve vision and of diagnosing and sometimes treating diseases of the eye) consult after Resident 37 reported his missing prescription eyeglasses. This deficient practice had the potential to result in Resident 37's worsening of eye vision that would negatively affect his quality of life and would put him at risk for fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one out of eight sampled residents (Resident 52) had a low bed and bilateral floor mats for safety per physician's order. This deficient practice put Resident 52 at risk for injury if she had a fall.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Measure the arm circumference and external catheter (a long, thin, flexible tube inserted in the vein to deliver medicine) length for one out of two residents (Resident 56) who had a midline catheter (a thin, soft tube that is placed into a vein, usually in the upper arm). This deficient practice had the potential for staff to miss any complications associated with a midline for Resident 56.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of eight sampled residents (Resident 41) received monitoring for his oxygen saturation (level of oxygen in the blood) to maintain it greater than 92% per physician order. This deficient practice had the potential to result in Resident 41 needing oxygen and not receiving it due to a lack of monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Post the updated daily nurse staffing information that included facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses (RN's), Licensed Vocational Nurses (LVN's), and Certified Nurse Aides (CNA's), along with resident census at the beginning of each day. This deficient practice had the potential of not having the information available to the residents and public in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one out of eight sampled residents (Resident 40) had a Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) completed for the month of November 2024. This deficient practice put Resident 40 at risk of having a drug interaction.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Ensure one of eight sampled residents (Resident 6) had monthly Complete Blood Count ([CBC]- a blood test that measures the number and type of cells in your blood) and Complete Metabolic Panel ([CMP]- a routine blood test that measures 14 substances in your blood to provide information about your metabolism, fluid and electrolyte balance, and how well your liver and kidneys are working) lab work drawn as ordered. 2. Ensure one out of eight sampled residents (Resident 40) had a CBC, and Basic Metabolic Panel ([BMP]- a blood test that measures eight different substances in the blood) completed per physician's orders. This deficient practice had the potential for Resident 6 and 40 to experience a delay in treatment.

Inspectors wroteBased on observation and interview, the facility failed to ensure: 1. Three out of four dumpsters had the lid closed. This deficient practice had the potential to attract rodents to the trash area.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide the average daily census in the Facility's Assessment (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services). This deficient practice had the potential to place residents at risk for delay of care and treatment services due to inability of the facility to plan for staffing needs of the resident and to allocate resources.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the pain management consult report for one of three sampled residents (Resident 56) was accessible and filed in their medical records. This failure had the potential to place Resident 56 at risk of not receiving appropriate care and delay in communication among staff due to incomplete medical records. 2. Indicate the correct discharge disposition for one of two sampled residents (Resident 97). This failure had the potential to lead to inadequate support services and safety concerns for the resident after discharge.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a resident who had a diagnosis of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) understand the legal documents (documents affecting the legal rights of any person) including binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not and the decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) she signed during admission to the facility for one of four sampled residents (Resident 32). This deficient practice resulted for Resident 32 signing a facility contractual agreement without her full understanding.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Provide at least 80 square feet ([sq. ft.] unit of measurement) per resident in multiple resident bedrooms for 31 out of 34 resident rooms. The insufficient space could lead to inadequate nursing care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's abuse prevention policy and procedure (P&P) was implemented for one of four sampled residents (Resident 9) when Certified Nursing Assistant (CNA) 1 failed to immediately report a verbal resident-to-resident altercation on 12/8/2024, between Resident 9 and Resident 10, to the supervising licensed nurse. This deficient practice resulted in Resident 9 being left in Room A with Resident 10, where Resident 10 then repeatedly struck Resident 9 in the face, and Resident 9 sustained pain to her head and face, and verbalized fear of further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 had the appropriate compentencies and skills required when reporting resident abuse immediately after witnessing a resident-to-resident altercation between two of four sampled residents (Resident 9 and Resident 10). This failure placed Resident 9 at risk for continued abuse by Resident 10, and any resulting physical and/or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three sample residents (Resident 1) was free from physical abuse when Resident 2 punched Resident 1 in the face. This deficient practice of not monitoring Resident 1 ' s whereabouts resulted in Resident 1 being punched in the face by Resident 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of three sampled residents (Resident 1) had a care plan (the process of identifying a patient ' s needs and how they can be supported) for food brought in from the outside of the facility being left at the bedside. This failure placed Resident 13 at risk of not having his care needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of three sampled residents (Resident 1) food items were labeled and dated at Resident 1 bedside. This deficient practice of not keeping track of Resident 1 ' s food items at the bedside had the potential to cause a foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a federally mandated resident assessment tool) was completed accurately for one of five sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 ' s Depakote (is an anticonvulsant and mood stabilizer medication) medication was coded as anticonvulsant and reflected in the MDS assessment under Section N (N0415-High-Risk Drug Classes) Medications. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that three of seven sampled residents (Residents 1, 2, and 6) were free from physical abuse when the following occurred: 1. Resident 7 punched Resident 2 in the face after Resident 2 entered Resident 7 ' s room and stole a jar of instant coffee without permission on 10/10/24. 2. Resident 2 threw a cup of coffee and kicked Resident 1 on 10/11/2024. 3. Resident 2 kicked Resident 6 in the left leg after Resident 6 confronted Resident 2 for attempting to steal a jar of Resident 6 ' s coffee. These deficient practices resulted in Resident 2 being punched in the face, Resident 1 suffering a left thumb wound, and Resident 6 being kicked causing severe left leg pain.

Inspectors wroteBased on interview and record review, the facility failed to implement and revise the care plan interventions, initiated on 8/27/24, for one of eight sampled residents (Resident 2) to address his continued behavior of stealing residents food (Resident 1, Resident 6, and Resident 7). This deficient practice resulted in Resident 2 ' s continued thefts causing psychosocial distress for Resident 1, Resident 6, and Resident 7, and three resident-to-resident altercations that occurred on 10/10/24, 10/11/24, and 10/26/24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure landing mats (cushions placed on the ground to minimize injury from a fall) were placed to both sides of the bed for one of six sampled residents (Resident 4). This deficient practice increased the potential for avoidable physical harm to Resident 4 related to possible injury sustained from a repeat fall.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) when it did not involve the Interdisciplinary Team (IDT) in discharge planning for two of three (Resident 1 and Resident 2) residents. This failure had the potential to result in resident goals, needs, and preferences to be unmet after discharge. a) During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (illness affecting blood flow to the brain), psychoactive substance (substance that affects how the brain thinks) abuse-induced psychotic disorder (overuse resulting in mental illness), and insomnia (disorder that affects sleep). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of discharge and the right to appeal, was provided to one of 3 residents ' (Resident 2) representative, prior to the resident ' s discharge to an assisted living facility (housing that provides nursing care, meals, and laundry services) on 10/2/2024. This failure resulted in Resident 2 ' s representative not knowing about Resident 2 ' s discharge.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility staff failed to: 1. Report immediately (right away) to the Administrator (Admin) or designated representative, the allegation of abuse, mistreatment on 5/28/2024, night shift (11p.m. to 7 am.), as indicated in the facility ' s Operational Manual- Abuse & Neglect, titled Abuse-Reporting and Investigations. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the allegation of abuse on 5/28/2024, night shift (11p.m. to 7 a.m.), for one of three sampled residents (Resident 1), was investigated. This deficient practice placed Resident 1 at risk for further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of three sampled residents (Resident 1), indwelling catheter (tube that drain urine from the bladder to a drain bag), was secured with anchoring device (a device to keep catheter tubing in place to prevent pulling, dislodgement). This failure had the potential for the catheter to get accidentally pulled out, causing pain, injury, and possible ([UTI] an infection in any part of the urinary system).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was turned, and repositioned every two hours. This failure placed Resident 1 at risk for delay in wound healing, worsening of wound condition and risk for further skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the indwelling foley catheter (catheter tube draining urine from bladder into a bag outside the body) bag for one of 3 sampled residents (Resident 1) was not on the floor. This failure placed Resident 1 at risk for cross contamination and urinary tract infection (UTI- urine infection).

Inspectors wroteBased on interview and record review, the facility failed to administer 2 of 5 sampled resident ' s (Residents 2 and 3) medications timely as ordered by the physician. This deficient practice placed Residents 2 and 3 at risk for subtherapeutic drug levels (level too low to produce intended medical effect) and worsening of medical conditions or symptoms.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified regarding one of three residents ' (Resident 1) refusal to take medications. This failure placed Resident 1 at risk for medical complications that would lead to hospitalization and/or death.

Inspectors wroteBased on interview and record review, the facility failed to reassess a resident ' s pain level after administration of pain medication for one of three sampled residents (Resident 1). This failure resulted in Resident 1 ' s unresolved pain and had the potential to affect Resident 1 ' s highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to check resident's blood sugar ([BS] main sugar found in the blood) levels and failed to administer medications as ordered by the physician for 1 of 4 sampled residents (Resident 1). These failures placed the resident at risk for diabetic reactions and potential life-threatening medical complications requiring hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess residents ' pain and implement its policy and procedure (P&P) titled, Administration of Pain Medication, which indicated Licensed Nurses should administer residents ' pain medications according to the physician's order, for two of three sampled residents (Resident 1, and Resident 3). This deficient practice resulted in Residents 1 and 3 experiencing unresolved pain for extended periods. It also caused Resident 3 to have abnormal vital signs (measurements of the body's most basic functions [blood pressure, heart rate, temperature, respiratory rate, and pain level) from 7/21/2024 to 7/22/2024 which required transfer to a general acute care hospital (GACH) for evaluation and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for two of three sampled residents (Resident 1 and Resident 5) by failing to: 1. Call the physician when Resident 1 requested for Trazadone (sleeping medication) to assist Resident 1 to sleep on 7/29/2024. 2. Assess and report to the physician to obtain treatment orders when Resident 5 was observed with small scratch and light skin discoloration on the left upper arm on 7/30/2024. This deficient practice had the potential to cause Resident 1 inability to sleep at night, affecting Resident 1 ' s quality of life. The deficient practice had the potential to result in Resident 5 ' s left arm skin issues to become worst and infected when interventions were not provided timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents' (Resident 4) feet were offloaded (off pressure) to prevent pressure injuries (damage to the skin and underlying soft tissue caused by prolonged or severe pressure). This deficient practice of not offloading (minimizing or removing weight placed on the foot to help prevent and heal ulcers) the feet had the potential of causing pressure injuries to the heels of the feet.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food according to the facility's menu for two of three sampled residents, (Resident 1 and Resident 6). This resulted in residents not eating food according to the physician's order and had the potential for the residents' nutritional needs not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food palatable (appetizing) for two of three sampled residents (Resident 1 and Resident 6). This deficient practice had the potential for residents' poor meal intake and weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three Residents (Resident 5) had a revised care plan for pressure ulcers. The deficient practice had the potential for repeat occurrences

Inspectors wroteBased on interview and record review the facility failed to: 1. Receive the necessary treatment and services related to pressure ulcers for two of three sampled residents (Resident 5 and 6) that were complete and accurately documented by nursing. This deficient practice had the potential for Resident 5 and 6 to acquire new pressure ulcers and/or worsen current pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents ' (Resident 1) care plan on elopement (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) was updated after Resident 1 attempted to elope on 2/24/2024, while out on pass (OOP), with Family Member 1 (FM1). This failure resulted in Resident 1 eloping with FM2 on 7/20/2024 while OOP, exposing Resident 1 to alcohol exposure and placing Resident 1 at risk to alcohol intoxication, accidents, and injuries, leading to hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 1), who was at risk for elopement (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) and had history of eloping on 2/24/2024, had a physician ' s order to go out on pass ([OOP] request by a resident to leave the hospital for a period of time and returns to continue their treatment that is ordered by physician) on 7/20/2024. This failure resulted in Resident 1 ' s admission to a general acute care hospital (GACH) on 7/21/2024 for evaluation/treatment/drug toxicology screening. This failure had the potential to cause accidents and severe medical complications and possible death.

Inspectors wroteBased on interviews and record review, the facility failed to provide wound care treatment ordered for three out of five sampled residents (Resident 2, 3, and 4). This failure had the potential to delay wound healing and cause wound infections.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide care in a manner that maintained or enhanced resident's dignity and respect in full recognition of his individuality for one of six sampled residents (Resident 2) when Business Office Staff (BOS) yelled at Resident 2. This deficient practice had the potential to negatively affect the psychosocial well-being of Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the physician was notified for one of six sampled residents (Resident 1) who had the behavior of refusing medications and activities of daily living ([ADL] daily self-care activities) care. This deficient practice had the potential to result in delayed necessary care and medical intervention.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a comprehensive and resident-centered care plan (the process of identifying a patient ' s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for one of six sampled residents (Resident 1) who had the behavior of refusing medications and activities of daily living ([ADL] daily self-care activities) care. This deficient practice had the potential to negatively affect the delivery of necessary care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure facility staff had mandatory abuse training upon orientation for one of one randomly selected staff. This deficient practice had the potential for the facility staff not knowing on how to prevent abuse and the knowledge to minimize the risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician order was implemented timely, for 1 of three residents, Resident 2. This failure resulted in the delay in obtaining results and the potential to delay medical care necessary to plan the care for the affected resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe safe and sanitary food preparation practices in the kitchen by failing to ensure: 1. Dietary Aid (DA 1 and DA 2) properly wore hair restraints (hairnet or caps used to prevent hair from contacting food) while in the kitchen. 2. DA 2 donned (put on) gloves prior to handling food. 3. DA 3 did not store personal bottled water in the resident freezer. 4. Dietary [NAME] (DC) performed handwashing after using her cell phone and prior to touching cooking utensil. These failures had the potential for cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness to residents who received food from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for two of five sampled residents (Resident 1 and Resident 4) when: 1. Certified Nursing Assistant (CNA) 1 struck Resident 1 with latex medical gloves ([gloves] disposable medical gloves used during medical examinations and procedures) on 5/21/2024. 2. CNA 4 held Resident 4's upper extremities to restrain him while Resident 4 was in bed on 5/7/2024. These deficient practices caused Resident 4 to sustain two skin tears (a traumatic wound that is caused by direct contact between the skin and another object) to the right forearm and right wrist, with moderate pain and bleeding. These deficient practices also had the potential to result in physical and psychosocial harm to Resident 1 and 4.

Inspectors wroteBased on interview and record review, staff failed to allow one of five sampled residents (Resident 4) to exercise their rights and preferences for care when Certified Nursing Assistant (CNA 4) turned off Resident 4's bedside light without asking permission to do so, and against Resident 4's wishes. This deficient practice had the potential to cause psychosocial distress and frustration for Resident 4, and removed the resident's autonomy to perform tasks of their choice when and how they wanted.

Inspectors wroteBased on interview and record review, staff failed to report an alleged incident of staff-to-resident abuse for one of five sampled residents (Resident 4) following an incident between Resident 4 and Certified Nursing Assistant (CNA) 4 on 5/7/2024. This deficient practice had the potential to cause a delay in the notification of necessary State and local agencies and the timeliness of their investigations, and increased the potential for additional staff-to-resident abuse incidents to occur as CNA 4 worked 11 additional shifts until he was suspended pending an investigation into the alleged abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1), was not physically abused by Resident 2 (perpetrator), as evidenced by: 1. Resident 1 was punched in the face with a closed hand by Resident 2, while smoking on the smoking patio. This failure resulted in Resident 1 feeling scared and helpless.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse policy and procedure (P&P). This violation put Residents 1 at risk of further physical abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) with interventions that included monitoring and follow-up care for four of six residents (Residents 3, 4, 5 and 6) after a resident-to-resident altercation where Resident 3 was hit in the back of the head with a book by Resident 4. This failure had the potential to cause a delay or lack of necessary care for Residents 3, 4, 5, and 6 following a resident-to-resident altercation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided when a resident, with a known history of striking out at peers and staff, exhibiting unpredictable episodes of verbal and physical aggression, and was arrested and issued a misdemeanor (type of offense punishable under criminal law) on 12/3/2023, was left without one-to-one supervision in the smoking patio with seven other residents for one out of seven sampled residents (Resident 1). This failure had the potential to result in Resident 1 striking out at other residents, visitors, or staff member in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a competency assessment skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) checks were performed upon hire for four of five randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] resident assessment and care screening tool) was accurately coded for one of one sampled resident (Resident 86). This failure had the potential to result inaccurate care and services for the residents due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a fall risk care plan for one of eight sampled residents (Resident 42) who was at risk for falls. This deficient practice had the potential to place Resident 42 at risk for fall and injury from a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff supervision during smoke breaks on the outside patio for one out of 8 residents (Resident 92). This deficient practice resulted in Resident 6 hitting Resident 92 over a cigarette while unsupervised.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician ordered medications were given in a timely manner for one of four sampled residents (56). This failure had the potential for the residents' prescribed treatments to be ineffective.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to: 1. Label four medications with an open date for a floor stock or house supply in medication cart three. 2. Label Resident 45's Ipratropium-Albuterol Inhalation Solution (a medication that is inhaled, prescribed for conditions that cause difficulty breathing) with an opened date. This deficient practice had the potential to result in the prolonged use and loss of strength of the floor stock medications and inhalation solution and can lead to ineffective treatment of respiratory symptoms.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff members personal beverages were not stored in one of 2 kitchen refrigerators. This deficient practice had the potential to result in cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms for 31 out of 31 resident rooms. The insufficient space could [NAME] to inadequate nursing care to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with respect and dignity when Resident 1's personal possessions and clothing were left outside in the open at the back of the facility's building. This failure had the potential for Resident 1's personal possession at risk of being stolen, lost, pest infestation, exposure to rain or sun, and resulted in Resident 1 being upset and having feelings of being treated unfairly.