View Park Convalescent Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:Kitchen and storage areas were not free from dirt and food debris. Reach-in refrigerator 2's bottom shelves contained dirt and dust debris. Reach-in refrigerator 1's vent, shelves, walls, roof and pipe had white spots, dirt and dust accumulation. Reach-in freezer 4 had dirt and food debris on the bottom shelves. Dry storage racks had dust buildup. A fan contained dust by the dishwashing machine was blowing air to the silverwares. Six (6) of 6 carts had old sticker residues. Drying racks had food and dirt debris. Disposable spoon drawer had dirt debris. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: Two (2) of 2 grey trash cans were not completely covered whennot actively in use during lunch service. One (1) of 2 dumpster's (a movable waste container designedto be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) cover was not tight fitting and it had space in between the closure. These failures had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread diseases to 84 of 84 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not meet standards of quality when licensed staff failed to follow or clarify physician medication orders for two five residents (Residents 4, 63, and 44) by failing to:A. For Resident 4, facility licensed nurse did not dilute potassium chloride (used to treat low blood potassium) prior to administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) in accordance with manufacturer's specification and physician's order. B. Facility failed to ensure the correct medication dose of ferrous sulfate (used to treat anemia caused by low amounts of iron in the blood) was available and administered to Resident 4 between 4/2026 - 6/2026 as ordered. C. [...]

Inspectors wroteBased on observation, interview, and record review, for one of one sampled resident (Resident 9), the facility failed to:1. Notify a physician that Resident 9 had an indwelling catheter (a thin flexible tube that drains urine from the bladder {organ that holds the urine before voiding}) from 7/2023 to .7/2026 to obtain a urologist consult2. Ensure Resident 9 received bladder and bowel (B&B) training program (a program of toileting schedule to try to restore or overcome urinary and bowel incontinence) while resident had the indwelling catheter according to Resident 9's B&B assessment dated [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) orders, in accordance with physician orders and facility policy and procedures (P&P) titled, Enteral Tube Medication Administration, for three of three sampled residents (Resident 4, Resident 63, Resident 32) administered medications via G-tube by failing to ensure: (Cross Reference F726, F759 and F760)A. Resident 32's G-tube was flushed with prescribed amount of water after medication administration B. Resident 63 G-tube was flushed with prescribed amount of water before, after, and during medication administration C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurses (LVNs) received training and demonstrated competency in performing medication administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) prior to administering medications to three out of three sampled residents (Resident 4, Resident 32, and Resident 63). This failure had the potential to place Resident 4, Resident 32, and Resident 63 at risk for inconsistent, incomplete, or improper medication administration via G-tube, which could result in a change of condition, adverse reactions, and decline in residents' health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration and accurate accountability of controlled medications (medications with a high potential for abuse) and disposal of non-controlled medications by failing to:A. Notify the physician for one of two sampled residents (Resident 4) when ferrous sulfate (a condition caused by low amounts of iron in the blood) 300 milligrams (mg, unit of measurement by weight)/ 5 milliliters (ml, unit of measurement by volume) was unavailable between 4/2026 through 6/2026 and ensure the resident was not administered the ferrous sulfate 220 mg/ 5 ml without a physician's order. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Five medication errors of 28 total opportunities contributed to an overall medication error rate of 17.86 % affecting three of five residents observed for medication administration (Resident 4, Resident 44, and Resident 63). The medication errors noted were as follows:A. For Resident 4, facility licensed nurse did not dilute potassium chloride (used to treat low blood potassium) prior to administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) in accordance with manufacturer's specification and physician's order. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five residents (Resident 4 Resident 63) were free of a significant medication error (any preventable error in medication administration that can result in resident discomfort, jeopardizing health and safety, or requiring medical intervention) by failing to:A. Ensure Resident 4's potassium chloride (used to treat low blood potassium) was diluted with water prior to administration via gastrostomy tube (G-tube, care for a feeding tube placed through the abdomen into the stomach to help deliver food or medicine) on 7/1/2026, in accordance with manufacturer's specification and physician's order. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of the residents when [NAME] 1 added additional gravy to the Swedish meatballs instead of two (2) ounces (oz, unit of measurement) of gravy as indicated on the menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) This failure had the potential to result in increased of food and nutrient intake to 53 of 84 residents on regular, therapeutic diets (a personalized meal plan prescribed by a healthcare professional or registered dietitian that controls the intake of specific foods or nutrients), resulting in unplanned weight gain.

Inspectors wroteBased on interview, observation, and record review, the facility failed to Implement and maintain an effective infection prevention and control program by failing to:1. Ensure Licensed Vocational Nurses (LVNs) followed the facility's policy and procedures titled, Enhanced Barrier Precautions, and Handwashing/Hand Hygiene, during medication administration for four of five residents (Resident 32, Resident 44, 63, and Resident 74) observed during the medication administration task.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy and dignity of one of one sampled (Resident 42)when staff failed to ensure Resident 42's left hip and thigh were not exposed and completely covered in facility hallway while Resident 42 was being transported from the resident room to facility shower room according to the facility's policy and procedures (P&P) titled, Resident Rights, reviewed 3/20/2026. This deficient practice resulted in Resident 42 complaining of feeling bad, didn't like it, and felt exposed and had the potential to cause the resident to suffer psychosocial (mental, emotional, social, and spiritual effects) harm due to exposure of parts of resident's body to other residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the June 2026 Activity Calendar, facility information, rules and regulations and weekly meal menu in a language one sampled resident (Resident 70) can read and understand. This failure resulted in Resident 70 inability to read and understand the June 2026 Activity Calendar, facility information, rules and regulations and weekly meal menu posted and had the potential for Resident 70 to not effectively communicate needs, understand care instructions, and participate in care planning.

Inspectors wroteBased on interview and record reviews the facility failed to ensure one out of three sampled residents (Resident 1) had a completed informed consent (a principle in medical ethics, medical law, and media studies, that a resident or resident representative must have sufficient information and understanding before making decisions about their medical care) for Ativan (an anti-anxiety medication) 1mg (milligram-unit of measurement) po (by mouth) prior to administering a one-time dose on 8/13/2025. This deficient practice infringed on the rights of Resident 1 to make an informed decision and had the potential for the resident to receive unwanted medication.

Inspectors wroteBased on interviews and record review, for one of three residents (Resident 1) identified as at high risk for falls, the facility failed to: Develop a comprehensive care plan to prevent falls and or with injuries for Resident 1. Ensure Resident 1's initial Fall Risk Evaluation was complete and accurate. These deficient practices potentially caused Resident 1 to fall on [DATE] at 5 A.M., and experienced pain, to the right hip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper transportation arrangements were made for one of three sampled residents (Resident 3). This deficient practice resulted in the delay of necessary doctor's appointments and blood work appointments (a test used to look at overall health and find a wide range of conditions) for Resident 3. Resident 3 missed a doctor's appointment on 6/4/2025 due to the facility arranging a non-bariatric (extra-wide, and extra-comfortable chair) van and missed another doctor's appointment and bloodwork on 7/15/2025 due to the facility arranging a non-gurney van.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure proper sanitation and food handling practices by kitchen staff failing to ensure: 1. cilantro, lettuce and carrots were properly labeled with delivery date and use by date when stored in the fridge and disposed of when brown and wilted. 2. one out of three dietary staff failed to wash their hands upon entry to the kitchen, after use of hairnet and before touching food in the refrigerator. This deficient practice had the potential to result in unsafe food management, and foodborne illness.

Inspectors wroteBased on interview and record review, facility failed to ensure dignity and respect for two of three sampled residents (Resident 1 and 3). This failure resulted in Resident 1 and 3 not being treated with dignity and respect when communicating with a mediation nurse and had the potential to affect the residents' self-esteem and self-worth.

Inspectors wroteBased on interview and record review, facility failed to ensure (Resident 1 and 3) were communicated in their preferred language. This failure resulted in Resident 1 and 3 not being able to understand some of the nursing staff this failure had the potential to affect the residents' self-esteem and self-worth.

Inspectors wroteBased on interview and record review, facility failed to ensure ordered pain medication was administered and the resident was educated on the ordered pain medications for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being confused as to what the ordered pain medications were and therefore not receiving the as needed pain medications for two days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain a clean, safe, and functional environment for 92 of 92 residents. 2. Maintain and repair leaking pipes. This failure had the potential to cause harm to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 4/17/2025 when the [NAME] (CK) failed to follow the recipe instruction for the Szechwan pork by adding salt, pepper and garlic powder. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss and increased risk hypertension (HTN - elevated blood pressure) for resident who were on a low sodium diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling practices when the container of Jelly in Refrigerator number one was dated 4/11/2024. This deficient practice 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 90 out of 99 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: maintain a sanitary environment by failing to adhere to infection control measures in one out eight bathrooms (room [ROOM NUMBER]) These deficient practices had the potential to expose Residents in room [ROOM NUMBER] to to disease causing pathogens (germs) from bodily fluids and waste that could result in, poor patient outcomes, medical complications, and unnecessary hospitalization. During a facility tour on 4/15/25 at 8 AM room [ROOM NUMBER] bathroom was observed to have: 1. Three visibly soiled towels hanging on the towel rack. 2. A used coffee cup with residue inside and a water pitcher and cup place on a shelf above the bathroom sink. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in 20 of 40 resident rooms (rooms 101, 102, 103, 104, 105, 106,107,109,110,114,116,118,120,121,122,134, 137, 138, 141). This deficient practice had the potential to result in inadequate space for nursing care and privacy and safety of residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to insulin was accurately documented to reflect the resident's insulin status for one of three sampled residents (Resident 80). This deficient practice had the potential to negatively affect Resident 80's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one out of 19 sampled residents (Resident 3) in obtaining dentures. This failure had the potential to effect the resident's nutritional status and weight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented infection prevention and control program by not wearing proper personal protective equipment (PPE - equipments including gloves, masks, gowns, face shields used to prevent spread of infection) when entering an isolation room (a type of hospital room that keeps patients with infectious illnesses away from other patients). There was an outbreak of influenza (Flu - is a contagious respiratory illness caused by influenza viruses) in the facility. This deficient practice had the potential for further spread of influenza risk of infections due to a break in infection control protocol during infectious disease outbreak.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), had an order for nothing by mouth (NPO-an acronym for the Latin phrase nil per os, which translates to nothing by mouth) as well as fingerstick blood sugar checks every six hours for a resident that as a NPO order and is on a gastrostomy (Gtube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding. This failure had the potential to result in inaccurate blood sugar monitoring for someone that is not taking nutrition by mouth and affect the care and services received.

Inspectors wroteBased on observation, interview and record review, the facility (Skilled Nursing Facility-SNF) failed to provide a safe environment to prevent falling for one of two sampled residents (Resident 1), by failing to ensure: 1. Maintenance Worker 1 (MW 1) notified Resident 1 and the resident's roommate/s that the floor was wet after mopping Resident 1's room with a wet mop. 2. MW 1 placed a wet floor sign on the floor in Resident 1's room to alert Resident 1 that the floor was wet. 3. MW 1 supervised/monitored the wet floor and re-directed Resident 1 to avoid the wet floor. As a result, on 10/25/2024, Resident 1 slipped and fell, and suffered severe pain of 10 out of 10 (10/10- a numerical pain scale assessment tool where zero is no pain and 10 is severe pain) to the left knee treated with opioids (a class of drugs used to treat moderate to severe pain). [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to (California Department of Public Health (CDPH) within two hours for one of three sampled residents (Resident 1). This deficient practice resulted in a delayed onsite investigation of by CDPH with a potential of further altercation between Resident 1 and Resident 2 Findings During a review of Resident 1's Face sheet (admission Record), indicated Resident 1 was re-admitted to the facility on [DATE], with a diagnoses of acute kidney failure (when your kidneys suddenly stop working properly), and essential hypertension (a type of high blood pressure that occurs when there is no identifiable cause). During a review of Resident 1's History and Physical (H&P) dated 6/29/2024, indicated Resident 1 had the capacity for medical decision making. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. One of one staff was not following the manufacturer's guidelines when checking the concentration of the QUAT sanitizing (a chemical used for disinfection) solution. 2. Staff was not able to verbalize the facility Resident's food from home policy. These deficient practices had a potential to result to cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsanitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) for 77 of 77 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen failing by: 1. Improper Storage of Food A. Unlabeled, undated pasta, ranch dressing and expired cheese dated 2/12/2024. B. Uncovered, unlabeled and undated bacon slices. C. Unlabeled, undated, and expired food inside the resident's refrigerator. Staff's parmesan cheese, drink, and Italian dressing in the resident's refrigerator in the activity room 2. Poor air circulation for Freezer three (3) and four (4). 3. Equipment Cleanliness/Cross-contamination A. Dirt debris in the Freezer 3's bottom shelves. B. Refrigerator 2's vent had dust. C. Refrigerator 1's roof and bottom shelves had black dirt debris. D. Dry storage shelves had dust buildup. Crate used for scoop storage was on the floor in the dry storage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: A. One (1) of two (2) black dumpster (a large trash container designed to be emptied into a truck) and one (1) of one (1) blue dumpster were not covered for unknown amount of time. B. The trash area was not maintained free from trash, soiled gloves, and other dirt debris. This deficient practice had a potential for the trashes to attract flies, insects, rats, and other animals to the dumpster area, bringing diseases to 77 of 77 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when: 1. Two (2) cockroaches (a type of insect) were observed in the kitchen. 2. Multiple cockroaches (two cockroaches) were observed on the floor underneath the dish washing sink area. This deficient practice had the potential to result in food contamination, causing food borne illnesses (illness caused by consuming contaminated foods or beverages) among 77 of 77 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, facility failed to meet professional standards of quality for one of four sampled residents (Resident 3). This deficient practice had the potential to cause underdosing, overdosing and hospitalization. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included adult failure to thrive, dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), and hypertension (HTN -elevated blood pressure). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was free of significant medication error. This deficient practice had the potential to lead ineffective medication therapy, and result overdose or underdose, which could be fatal to Resident 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored and or disposed per the facility's policy and procedures titled Disposal of Medications and Medication-Related Supplies, subtitled, Controlled Medication Disposal revised 2/20/2024, and Labelling of Medication Containers revised 2/20/2024, by failing to: 1. Safely dispose wasted medications in one of four medication carts (Medication Cart B #2). 2. Label 34 out of 36 multiuse (non-prescription medication/over the counter medication that can be used for more than one resident) with an open date (date indicating packaging opened; used to determine amount of time food can be safely consumed). These deficient practices had the potential to: 1. Result in medication diversion and access by unauthorized persons. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three medications were not left with the resident who was not capable to self-administer medications for one of 18 sample residents (Resident 77). This deficient practice had the potential to result in, 1. Harm through drug interactions and/or allergic reactions, unnecessary hospitalizations, and even death for Resident 77. 2. Access to the medication by unintended person/residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that advanced healthcare directive information was provided to the resident's responsible party (RP) for two of eight sampled residents (Resident 1 and Resident 3). This deficient practice resulted in violation of Resident 1 and Resident 3's representative's rights to receive information on advanced healthcare directive and to formulate advanced healthcare directive for Resident 1 and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment by failing to secure/cover multiple exposed sheathed wires and connectors on the bed side rail for one of six residents (Resident 29). This deficient practice had the potential to result in injury/harm to Resident 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six Residents (Resident 288) was free from physical restraint. This deficient practice had the potential to result in lowered and or lost dignity and self-esteem and increased the risk for injury or death for Resident 288.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for a low air loss mattress (LALM - a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) for one of six sampled residents (Resident 9). This deficient practice had the potential to harm Resident 9 and for Resident 9 not to receive appropriate treatment and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to create a patient centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for two of six sampled Residents (Residents 9 and 288) by failing to: 1. Develop and implement a care plan for Resident 9's low air loss mattress (LALM: special mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown). 2. Develop and implement a care plan for Resident 288's full bed length side rails. These deficient practices: 1. Had the potential to delay healing, and placed Resident 9 at increased risk for developing new pressure injuries, worsening of existing ones, and complications resulting from untreated or improperly treated pressure injuries. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for two of six sampled residents (Residents 6 and 54) This deficient practice resulted in Residents 6 and 54 feeling angry and also had the potential to develop skin infections, skin irritation, and foul odor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the settings for a Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) were correct and appropriate to the weight of one of six sampled residents (Resident 9). This deficient practice had the potential for Resident 9 to develop pressure injuries (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the tube feeding product/formula was not hanged for more than 48 hours per manufacturer's instructions and facility's policy and procedures for one of two sampled residents (Resident 3), These deficient practices had the potential to result in abdominal pain, vomiting, and loose bowel movement because of bacteria growth for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure five of five staff were assessed for competency upon hire and annually. This deficient practice had the potential for a knowledge, training, and certification deficit among staff, leading to inadequate or delayed resident care.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents by failing to ensure facility policy for multi-use medications in medication cart (Medication Cart B #2). This deficient practice had the potential to cause inability of the facility to readily identify medications that have a limited time for use once opened and had the potential for poor therapeutic outcomes due unintentional administration of expired medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in 52 of 84 resident rooms (rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 116, 118, 120, 121, 122, 134, 137, 138, 141). room [ROOM NUMBER] had one bed. Rooms 103, 109, 114, 134, 137, and 141 had two beds inside each room. Rooms 101, 104, 105, 106, 107, 110, 116, 118, 120, 121, 122, 138, 142 had three beds inside each room. This deficient practice had the potential to result in inadequate useable living space for the residents to ensure their freedom and safety and inadequate working space for the health caregivers to provide care to the residents.

Inspectors wroteBased on interview, and record review, the facility failed to implement it's policy and procedures (P &P) titled, Consent for Procedures and Medical Treatment, by failing to ensure the resident representative (RP) consent was obtained prior to getting a debridement (is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) done for one of three sample residents (Resident 1). This deficeint practice had the potential to place Resident 1 and the RP at risk for not being able to understand the benefits and reasonable risks associated with the procedure and make an informed decision.

Inspectors wroteBased on interview and record reviews, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) for the pressure ulcers (PU- Injury to skin and underlying tissue resulting from prolonged pressure on the skin) to Resident 1 ' s Sacral coccyx (bones that complete the lower spine and help provide stability and function to the lower back and legs) upon identification on 11/6/2023. This deficient practice had the potential to result in negative impact on Resident 1 ' s wounds healing thereby affecting health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two ice coolers in the hallways of the facility were locked. This deficient practice had the potential to result in residents helping themselves to ice and possibly not following proper safety procedures. During an observation with concurrent interview on 1/17/24 with Registered Nurse Supervisor (RNS) 1 in front of nursing station B. An ice cooler with a padlock closure in the unlocked position was observed. The RNS stated the kitchen staff are responsible for the ice cooler. During an observation with concurrent interview on 1/17/24 with LVN 2 in the front hallway of the facility adjacent to Nursing station A. An ice cooler was observed to be unlocked. LVN 2 stated it is empty but should be locked. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an environment that was free of accident hazards for one of six sampled residents (Resident 2), by failing to ensure resident had bed side rails as part of the resident ' s individualized care plan for preventing falls. This deficient practice resulted in Resident 2 falling on 1/7/24 requiring transfer to the GACH (General Acute Care Hospital).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow it ' s policy and procedures for bed side rails for one of six sampled residents (Resident 2), by failing to ensure Resident 2 had and order for bed side rails and a care plan was developed for bed side rails. This deficient practice had the potential to result in risk of entrapment for Resident 2. Cross reference with F689.

Inspectors wroteBased on interview and record review, for one of six sampled residents (Resident 1), the facility failed to immediately transfer Resident 1 via 911 (telephone number used to reach emergency medical, fire, and police services) to a General Acute Care Hospital (GACH) in accordance with the American Heart Association (AHA- an organization that funds cardiovascular (cardio [heart] vascular [blood vessels]) medical research, educates consumers on healthy living and fosters appropriate cardiac (pertaining to the heart) care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke) Stroke (a medical emergency due to loss of blood flow to part of the brain) guidelines dated 2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 1. Ensure one of four sampled residents (Resident 1), had measures in place to prevent pressure sores (pressure ulcer/ injury or bed sore, an injury to the skin that develops over bony areas of the body from prolonged pressure to the area) from developing. This failure resulted in Resident 1 developing a new pressure sore on right heel and a re-ulceration (reopening) of previously healed pressure sore on sacrum (a triangular bone in the lower back). 2. Implement its policy and procedures for pressure sore management to take a picture of a pressure sore on admission available in the resident ' s medical chart for two of six sampled residents (Residents 2 and 5). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to 1. Ensure one of four sample residents (Resident 7) was not left wet for extended periods. This failure resulted in Resident 7 being left wet for over 40 minutes. 2. Ensure one of four sample residents (Resident 5) urine was assessed as being abnormal in color and transparency and reported to the medical doctor. This failure had the potential to result in Resident 7 developing a urinary tract infection (UTI, an infection in any part of the urinary system) and delay treatment.