Visalia Post Acute

Inspectors wroteBased on interview and record review, the facility failed to implement one of three sampled residents (Resident 1) care plan when Resident 1's physician was not notified of Resident 1's episodes of aggression (behavior intended to cause harm can be physical actions or verbal attacks). This failure resulted in a delay of physician notification placing Resident 1 and other residents at risk for continued aggressive behavior.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement one of three sampled residents (Resident 1) comprehensive care plan when no documentation was completed for Resident 1 with a known behavior of manipulating and pulling dialysis catheter (a tube placed into a large vein to access the bloodstream to filter toxins from the blood). This failure had the potential for inconsistent care and severe infection to Resident 1's dialysis site.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was implemented after a resident to resident altercation for two of three sampled residents (Resident 1, Resident 2). This failure had the potential for the staff to be unaware of an ongoing infection and the potential for further incidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were implemented for one of three sampled residents (Resident 1) when wound care was not initiated upon return from the hospital. This failure resulted in a delay of care to Resident 1's cellulitis (serious bacterial infection affecting the deep layers of the skin and the underlying tissues).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) titled, Safety and Supervision of Residents for one of two sampled residents (Resident 1) when Resident 1 was outside the patio area without supervision. This failure resulted in Resident 1 having unwitnessed fall, sustaining a fracture (broken bone) to the right humerus (long bone of the upper arm). FindingsDuring a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 is [AGE] years old, was admitted on [DATE] with diagnoses of muscle weakness, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), unsteadiness on feet, difficulty in walking, dizziness, and history of falling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician's order for the use of side rails (a safety device or structural support installed on beds, to prevent fall, assist with repositioning, and provide stability when getting in and out of bed). This failure had the potential for inappropriate use of side rails and potential for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) needs were met when the bed was not long enough. This failure resulted in Resident 2 being uncomfortable due to not being able to extend his legs while in bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their policy and procedure was followed when medications were left at the bedside for one of three sampled residents (Resident 1). This failure had the potential for the staff to be unaware if the medication was taken by Resident 1and put other residents at risk for ingesting the medication and experiencing an adverse reaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective grievance process for three of 33 sampled Residents (Residents 122, 66, and 120), when: 1. Resident 122 was not aware of the facility's response to her grievance related to visiting her friend in the facility and expressed she continued to have issues visiting her friend. 2. Resident 66 reported missing clothes to Social Services Assistant (SSA) six months ago and no action was taken.3. Resident 120 requested assistance from SSA regarding scheduling surgery since admission. These failures had the potential to result in violation of resident's right to voice grievances, feel unheard and/or feel unsupported, and the lack of a functional grievance process left residents' concerns unaddressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Services Director and Social Services Assistant met the qualification requirements as stipulated by the regulation. This failure had the potential to result in misidentification or mishandling of residents' cases which can lead to poor interventions and lack of support for all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program (the facility's program for identifying problems and improving resident care) addressed concerns related to social services staffing qualifications, including the lack of a qualified Social Services Director (SSD) and Social Services Assistant (SSA), as part of the facility's ongoing assessment and performance improvement activities. The QAPI program failed to identify and address this concern. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program (the facility's program for identifying problems and improving resident care) to ensure resident and family complaints were consistently identified, documented, tracked, and analyzed through the QAPI process. This failure had the potential to prevent the facility from identifying systemic issues (problems that affect more than one resident or area of the facility), implementing corrective actions, and improving the quality of care and services provided to residents. On 03/04/2026 at 12:00 PM during a reviewed Facility Grievance Log there were only three grievances listed since March 2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that allegations of abuse and injuries of unknown origin were reported to the State Agency for three of 33 sampled residents (Resident 49, 22, and 153). This failure resulted in delay in initiation of an external investigation and ensure residents' safety and resident-to-resident abuse to go uninvestigated and leave vulnerable residents unprotected from further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program for 6 of 33 residents when:1. Certified Nursing Assistant (CNA) 2 obtained vital signs (pulse rate, temperature, respiration rate, and blood pressure) without disinfecting the equipment between use for Resident 100 and 93.2. CNA 1 did not wear a gown while providing toileting assistance to Resident 11 who was on Enhanced Barrier Precautions (EBP-gown and glove use to reduce spread of infection).3. Oxygen concentrator filters for Residents 6, 69 and 83 were observed covered with lint. These failures had the potential to increase the risk of cross-contamination and the spread of infection within the facility.1. During an observation on 3/2/26 at 2:33 PM in Resident 100's room, CNA 2 was observed obtaining Resident 100's vital signs. [...]

Inspectors wroteBased on an interview, and record review, the facility failed to coordinate discharge planning with the receiving facility and communicate with the resident and resident's responsible party (RP) for one of 33 sampled residents (Resident 122). In addition, the facility failed to ensure the discharge care plan reflected the residents' goals and resident specific interventions. This failure resulted in facility staff, Resident 122, and the resident's responsible party not being aware of the resident's discharge plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer insulin (medication used to lower blood sugar) within professional standards, when Lispro Insulin (fast acting insulin) was administered to one of 33 sampled residents (Resident 111) one hour prior to a meal. This failure had the potential to cause adverse outcome from hypoglycemia (a condition in which blood glucose concentration is below 70 mg/dl (unit of measurement) or harm to the residentFindings: Review of the admission Record indicated Resident 111 was admitted to the facility on [DATE], with diagnoses which includes Type 2 Diabetes Mellitus with Ketoacidosis (a serious health condition when the body can't make enough insulin). During an interview with Licensed Vocational Nurse (LVN) 1 on 3/4/2026 at 12 PM, LVN 1 was asked if she would be checking Resident 111's blood sugar prior to lunch. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective pain management was implemented for Resident 151 when:1. The as needed pain medication (Tylenol) for Resident 151 was not administered according to the physician's order.2. Resident 151's pain level was not assessed timely post-administration of the as needed pain medication. These failures had the potential to result in Resident 151's suffering and decreased mobility due to unresolved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: One of two treatment carts was left unlocked and unattended on station 3. Personal food items were stored in one vaccine refrigerator. This failure had the potential to allow unauthorized access to treatment supplies by residents, staff, or visitors and maintain a controlled and sanitary environment for the storage of vaccines. 1. During an observation on 3/3/26 at 8:35 AM, Station 3's treatment cart was observed across the nurses' station. The treatment cart was unlocked and unattended. During a concurrent observation and interview on 3/3/26 at 8:46 AM, with Licensed Vocational Nurse (LVN) 2, the treatment cart remained located across from the nurses' station against the wall and was still unlocked and unattended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety standards were met when: 1. A linear black substance was found inside the ice machine in the kitchen.2. Two open bags of pasta and one open cornstarch were found in the kitchen unlabeled and undated and were not stored in an airtight container.3. One unlabeled and undated partially consumed bottled drink was found inside the resident's nutrition refrigerator at Station 2.4. One unlabeled and undated partially consumed frozen yogurt was not found inside the resident's nutrition freezer at Station 2.5. [NAME] 1 covered his mustache while preparing food in the kitchen. These failures had the potential to result in foodborne illnesses to all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident call system was operational and accessible when;1. The call light system in Resident room [ROOM NUMBER] bathroom was observed with missing required pull cord, preventing the residents from summoning staff assistance when needed.2. The call light system in Resident room [ROOM NUMBER] bathroom had missing call button preventing the residents from summoning staff assistance when needed. This failure had the potential to prevent residents from summoning staff assistance in a timely manner, placing residents at risk for unmet needs, accidents, or injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physical environment was maintained in safe, clean and well maintained when;1. room [ROOM NUMBER] walls had large scuff marks present on the room walls and bathroom walls.2. room [ROOM NUMBER] bathroom vinyl flooring was lifted at the bathroom entrance. The facility's failure to maintain resident living areas in good repair had the potential to create an unsafe environment and increase the risk of trips, falls, or other injuries for residents, staff and visitors.

Inspectors wroteBased on observation and interview, the facility failed to provide the minimum square footage required by regulation for 11 of 50 resident rooms. During an observation on 3/3/26 at 10:01 AM, resident rooms 41-51 did not meet the required minimum square footage of 80 square feet per resident.room [ROOM NUMBER]: 227.2 sq. ft. (3 residents)room [ROOM NUMBER]: 219.2 sq. ft. (3 residents)Rooms 43-51: 234.5 sq. ft. (3 residents)During an interview on 3/6/26 at 9:15 AM with the Administrator (Adm), the resident room size waiver was discussed. The Adm acknowledged that rooms 41-51 did not meet regulatory requirements.

Inspectors wroteBased on interview and record review, the facility failed to follow up on physician orders for one of three sampled residents (Resident 1) when a left leg arterial duplex (ultrasound used to visualize blood flow in arteries) and venous duplex (ultrasound used to visualize blood flow in the veins) was not done. These failures resulted in a delay of treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, notify the physician and treat a change of condition for one of three sampled residents (Resident 1) when Resident 1's left foot 2nd toe was swollen, had drainage coming from it and dry crusty debris covering the top of the toe and the nail bed. These failures resulted in a delay of care and the potential for Resident 1's foot to worsen.

Inspectors wroteBased on interview and record review, the facility failed to reevaluate wounds when the treatment orders were ending for one of three sampled residents (Resident 1). This failure had the potential to result in worsening of Resident 1's wounds and going untreated.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders when there was no referral to the wound care doctor and treatment was not provided to one of three sampled residents (Resident 1) when it was ordered by the podiatrist. This failure resulted in Resident 1's wound going untreated and had the potential for Resident 1's wound to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of a change of condition for one of three sampled residents (Resident 1) when Resident 1's wound worsened. This failure had the potential for Resident 1 to experience a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) physician's orders were followed. This failure resulted in Resident 1 not receiving a dose of intravenous (IV - used to administer medications directly into the vein) antibiotics (used to treat infection) and the potential for Resident 1's urinary tract infection to worsen.

Inspectors wroteBased an interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the facility after hospitalization. This resulted in Resident 1 having unnecessary stay in the hospital and violated Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure adult protective services (APS) was notified for one of three sampled residents (Resident 1) when Resident 1 was discharged from the facility home alone, when staff had concerns for her safety due to Resident 1's cognitive status. This failure had the potential to result in Resident 1 having unmet care needs and being put at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) were offered and completed for 20 of 36 sampled residents (Resident 113, Resident 73, Resident 411, Resident 128, Resident 104, Resident 135, Resident 2, Resident 111, Resident 77, Resident 312, Resident 311, Resident 81, Resident 51, Resident 68, Resident 313, Resident 36, Resident 101, Resident 43, Resident 109, and Resident 84). This failure had the potential for residents' healthcare wishes to not be honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained and equipment was in good repair in accordance with professional standards for food service safety when: 1. The dishmachine and ice machine manufacturer's guidelines were not followed related to lack of a floor drain and lack of proper air gap to prevent the backflow of potentially contaminated water into the clean water supply. 2. Floor sink drains related to a steamer and hand washing sink were not maintained in a sanitary manner and in good repair in which pooled water could attract pests such as insects and rodents. 3. Clean foodservice equipment was stored on shelves with scattered dried food debris. 4. The foodservice operation lacked cleaning with detergent prior to sanitizing of food contact surfaces. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow infection control policies and procedures (P&P) as evidenced by: 1. Licensed Vocational Nurse (LVN) did not follow the facility P&P) titled Administering Medications to administer medications in a clean and sanitary manner for two of two residents (Resident 66 and Resident 143). This failure had the potential to result in infection and illness for Resident 55 and Resident 143. 2. Infection Preventionist (IPN), did not follow the facility P&P titled Surveillance for Infection and Monitoring Compliance with Infection Control for surveillance (monitoring) activities, collecting, analyzing, track and trending of data. This failure had the potential for facility to be unaware of outbreaks and the transmission of infectious diseases. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse [inappropriate treatment of an individual], Neglect [refusal to provide the needs of the resident], Exploitation [taking improper advantage of an individual], and Misappropriation [misuse, stealing from a resident] Prevention Program, annual training for the following: 1. 17 of 73 sampled Certified Nursing Assistants (CNA), CNA 1, CNA 2, CNA 33, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, CNA 16, and CNA 17), 2. Seven of thirty one sampled Licensed Vocational Nurses (LVN), LVN 4, LVN 15, LVN 6, LVN 10, LVN 8, LVN 19, LVN 100, 3. Four of twelve sampled Dietary Aids (DA), DA 1, DA 2, DA 3, DA 4, 4. Two of four sampled cooks, [NAME] 1, [NAME] 2, 5. Two of twenty Feeding Assistants (FA) FA 1, FA 2, 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Office of the State Long-Term Care Ombudsman (OSLTCO-independent advocate who helps protect the rights of residents) a Notice of Transfer when: 1. Facility transferred three of three sampled residents (Resident 51, Resident 68, Resident 127) to a local hospital and 2. Facility discharged (transfer without expectation of return to facility) one of one sampled resident (Resident 159) to a local hospital. These failures denied Resident 51, Resident 68, Resident 127, and Resident 159 immediate access to an advocate who could inform of transfer or discharge options and resident rights.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy & procedure (P&P) Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residents) for four of four sampled residents (Resident 62, Resident 134, Resident 101, and Resident 135) when: 1. admission Director (AD) did not explain the BAA to two of four sampled residents (Resident 62 and Resident 134) in a manner that he or she understood, before signing the agreement. 2. AD did not document a verbal acknowledgement of the BAA from four of four sampled residents (Resident 62, Resident 134, Resident 101, and Resident 135). This failure resulted in Resident 62, Resident 134, Resident 101, and Resident 135 not being fully aware and informed of their rights if there was a dispute with the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning wall light was provided in a resident's room for one of six sampled residents (Resident 139). This failure had the potential to compromise the safety of the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide written information on bed-hold (holding a resident's bed during hospitalization) for two of two sampled residents (Resident 51 and Resident 68). This failure had the potential to create uncertainty for Resident 51 and Resident 68 to return to the facility and return to their previous rooms.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Resident Matrix (MDSRM), was accurate and up to date for two of six sampled residents (Resident 135, and Resident 152). This failure had the potential for Resident 135 to have unmet care needs and inaccurate medical records for both Resident 135, and Resident 152.

Inspectors wroteBased on interview and record review, the facility failed to provide Baseline Care Plan (BCP - an initial person-centered care plan within the first 48 hours of admission that provide instructions for care of the resident) Summary for three of three newly admitted sampled residents (Resident 311, Resident 312, and Resident 313). This failure had the potential for Resident 311, Resident 312, and Resident 313 to not receive the care and the safeguards necessary within the first 48-hours of admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Doctor (MD) reviewed and countersigned a verbal order (VO) for two of two sampled residents (Resident 101 and Resident 127). This failure had the potential for the nurse to not properly follow the VO for Resident 101 and Resident 127.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Activities of Daily Living (ADL) for one of seven sampled residents (Resident 81) when nursing staff did not provide personal grooming and hygiene. This failure had the potential to result in Resident 81's lowered self-esteem and the potential make Resident 81 susceptible to disease and/or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 84) in Hospice Care (end of life care) received care and treatment for the edema (swelling) on both the legs when: 1. Weekly Nursing Assessments did not indicate Resident 84 had edema. 2. After Hospice Nurse (HPN) notified Medical Doctor (MD), MD did not provide treatment orders for Resident 84's edema. These failures resulted in Resident 84's not receiving the necessary services, treatment and quality of care needed for the swelling in both her legs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient communication between the facility's Registered Dietitian (RD) 1 and RD 2 employed by the dialysis center related to provision of lunch meal in a safe manner for one of one sample resident (Resident 139) who received dialysis three times a week. This failure had the potential to result in Resident 139's lunch to contain Time Temperature Control for Safety (TCS - food that requires time-temperature control to prevent the growth of bacteria) foods to include a turkey or tuna sandwich had inadequate monitoring of time/temperature control for food safety which placed Resident 139 at an increased risk for a foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its policy and procedure (P&P) on Resident Rights, for one of six sampled residents (Resident 106) did not receive routine dental services. This failure had the potential for poor eating and broken or lose teeth to go unnoticed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide the therapeutic diet as ordered for one of seven sampled residents (Resident 311) when: a. Resident 311 was served his nectar-thick (thickness of milkshake) drink and house nourishment after sitting out at room temperature for approximately five (5) hours on 1/27/25. b. Resident 311's meal tray did not have 8 fluid ounces (fl. oz) nectar-thick punch drink for lunch on 1/27/25. These failures had the potential for Resident 311 to not meet the nutritional requirements due to decreased palatability (tastiness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Honor resident's food preferences for two of 13 sampled residents (Resident 28, and Resident 51). This failure resulted in an unpleasant dining experience due to the facility serving both Resident 28 and Resident 51 food listed as disliked and Resident 28 not receiving soup under her standing orders. 2. Ensure one of seven sampled residents (Resident 51) was aware of the menu in time to request an alternative menu item. This failure had the potential for Resident 51's nutritional needs to not be met. 3. Provide alternative milk product for one of one sampled residents (Resident 311) who had lactose (milk sugar) intolerance (unable to digest). This failure had the potential for Resident 311 to not meet his nutritional requirements.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the minimum square footage as required by the regulation for 11 of 50 of the facility rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) call light was within Resident 1's easy reach. This failure had the potential for Resident 1 to not received assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak of scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) was not reported to the state health department for three of fourteen sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in the state health department being unaware of the outbreak.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) referral was made for one of two sampled residents (Resident 1). This failure resulted in a delay of the psychiatrist evaluation for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of three sampled residents (Resident 1) when the bed linen was not in good repair. This failure resulted in Resident 1's bed sheet having a hole and two areas where the sheet was discolored due to the thinning of the sheet.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) when a Family Member (FM) 1 made Licensed Vocational Nurse (LVN) 1 aware of the allegation of abuse. This failure had the potential for delayed investigation and place other residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide podiatry services for two of three sampled residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2 having long, jagged, discolored toenails.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician in a timely manner when one of three sampled resident's (Resident 1) continued to experience a change in condition. This failure resulted in a delay of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure wound treatments were provided for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's wounds to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure bowel movement (BM) documentations were completed for one of three sampled residents (Resident 1). This failure resulted in incomplete documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided supervision when staff failed to respond to a security door alarm going off in the dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) unit. This resulted in Resident 1 exiting the open security gate that provided access off of the facility grounds and being found approximately a quarter of a mile away from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided a safe environment when there was exposed staples from a missing drawer face on Resident 1 ' s night stand. This failure had the potential for Resident 1 to be injured by the exposed staples.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (RP) was notified when medication was discontinued for one of three residents (Resident 1). This failure resulted in the RP being unaware of a change in Resident 1 ' s medical care.

Inspectors wroteBased on interview and record review, the facility failed to ensure 9 of 66 sampled residents' (Resident 147, Resident 126, Resident 11, Resident 136, Resident 79, Resident 78, Resident 144, Resident 35, and Resident 61) information regarding Advanced Directives (AD - a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) was provided. This failure had the potential to result in Resident's being unable to make decisions about their medical care.

Inspectors wroteBased on interview and record review, the facility failed to ensure six of six sampled Licensed Vocational Nurses (LVN 1, LVN 2, LVN 3, LVN 4, LVN 5 and LVN 6) had annual competency (measurable pattern of knowledge, skills and abilities an individual needs to perform occupational functions successfully) evaluations. This failure had the potential to result in nursing staff to not have specific skills and training needed to care for resident needs.

Inspectors wroteBased on interview and record review, the facility failed to develop for 3 of 66 sampled residents' (Resident 136, Resident 73, and Resident 24) an individualized care plans when: 1. Resident 136 did not have an activities Care Plan (CP). 2. Resident 73 did not have a refusal CP. 3. Resident 24 did not have a CP indicating the use of bedrails. These failures had the potential for Resident's to not receive care specific to their preference or choice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow physician's orders (PO) for one of 66 sampled resident's (Resident 129) when Resident 129's blood sugars (BS) were not monitored and documented. This failure had the potential to result in unmet care needs and adversely affect resident's health. 2. Obtain a physician's order for one of 66 sampled resident's (Resident 120) when Resident 120 was administering oxygen (O2 A chemical element needed to breath) to himself. This failure had the potential for Resident 120 to receive the incorrect dose of oxygenation, which can adversely affect her health condition. 3. Obtain a physician's order for bedside rails for one of 66 sampled resident's (Resident 24). This failure had the potential to result in injuries and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents (Resident 73) was assisted with oral care. This failure resulted in Resident 73 having dental issues and tooth decay.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day, seven day per week. This failure had the potential to adversely affect resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents' (Resident 136) was placed on contact precautions after receiving a contagious infection diagnosis. This failure had the potential to result in the spread of infection to residents, staff and visitors.

Inspectors wroteBased on observation and interview, this facility failed to provide the minimum square footage as required by the regulation in 50 of the facility bedrooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents (Resident 42) call light system was properly working. This failure had the potential for Resident 42's care needs to be unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, assess, document, and notify a change in condition for one of three sampled residents (Resident 1) when Resident 1 was left outside of the facility for a prolonged period of time. This failure resulted in Resident 1 feeling hot and had the potential for Resident 1 to experience heat stroke (body overheating).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wheelchair was free of debris. This resulted in Resident 1 using a dirty wheelchair and the potential for spread of bacteria.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was developed for one of three residents (Resident 1) refusal of care. This failure had the potential for staff to not know how to provide care to Resident 1 when refusing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Podiatrist (doctor that treats the feet) recommendation for a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was followed upon for one of three sampled residents (Resident 1). This failure resulted in a delay in care for Resident 1 and the potential for Resident 1 to experience worsening of the pressure ulcer.