Vista Del Sol Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 2 and Resident 29) received care in a manner that maintained/enhanced dignity and respect by failing to ensure:1. Activity Assistant (AA) and Certified Nursing Assistant (CNA) 2 did not refer to Resident 2 and Resident 29, who needed assistance with meals, as Feeders (dehumanizing term for elderly individuals needing feeding assistance, can be a derogatory, objectifying term). 2. CNA 2 did not stand up when feeding Resident 29 during lunch. This failure had potential to negatively affect Resident 2 and Resident 29 sense of dignity and respect, for Resident 29 to feel rushed while eating.

Inspectors wroteBased on interview and record review, facility failed to promptly notify the physician and a resident representative when one of one sampled resident ( Residents 2) had a change in condition (COC - a clinical document used to record, assess, and report any sudden changes in a resident's physical, mental, or psychological status in order to ensure appropriate medical treatment can be started safely) evidenced by:1. When Resident 2 experienced six 6 pounds (lbs-unit of measurement) in 3/2026.weight loss2. When Resident 2 developed a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) This deficient practiced violated the rights of Resident 2 and the resident's representative and had the potential to delay the necessary/essential treatment and medical care and for Resident 2.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a comfortable, homelike environment for one out of five residents sampled (Resident 20). This failure resulted in Resident 20 not being unable to concentrate, rest, or sleep due to the continuous loud noises and conversations outside of the resident's door. Resident 20 was not allowed to close the door to reduce the noise level.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to Pre -admission Screening and Resident Review (PASRR -a safety check done before someone enters a Medicaid-certified nursing home to ensure the facility can meet their specific needs, or if they would be better served in the community) was accurately documented [NAME] to the facility's policy and procedure (P&P) titled Accuracy of Assessments, dated 1/2025 for one of six sampled residents (Resident 42). This deficient practice had the potential to negatively affect Resident 42's plan of care and delivery of necessary care and services. [...]

Inspectors wroteBased on observation, interview, and record review, for one of five sampled residents (Resident 8), the facility failed to:1. Complete the Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long-term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment when Resident 8's re-admitted to the facility on [DATE].2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/initiate a comprehensive care plan for constipation within seven days of admission on e of four residents (Resident 49) who was receiving medications for constipation (having fewer than three bowel movements per week, characterized by hard, dry, or lumpy stools that are difficult or painful to pass). This deficiency had the potential for the facility to not meet the needs and necessary services for Resident 49 and also the potential for hospitalization.

Inspectors wroteBased on interview and record review, facility failed to develop and implement a care plan for weight loss for two of two sampled residents (Resident 2 and Resident 49) according to the facility's policy and procedures (P&P) titled Develop-Implement Comprehensive Care Plans dated 1/2026. This deficient practice had potential to failure in the delivery of necessary care and services for Resident 2 and Resident 49.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate/develop a comprehensive care plan within seven days after re-admission for one of four residents (Resident 25) who was on oxygen therapy. This deficiency had the potential for Resident 25 to experience undesired health effects related to the administration of oxygen not limited to hypoxia (a dangerous medical condition where body tissues or organs do not receive enough oxygen, potentially causing severe damage or death within minutes), hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a change in condition (COC - a clinical document used to record, assess, and report any sudden changes in a resident's physical, mental, or psychological status in order to ensure appropriate medical treatment can be started safely) assessment was completed and appropriate interventions implemented for one of one sampled resident (Resident 2) who had diagnosis of severe protein-calorie malnutrition (severe deficiency and/or poor absorption of protein, calories and nutrients) when Resident2 experienced 5.35 percent (% - unit of measurement) weight loss in a month. This deficient practice had potential to failure in the delivery of necessary care and services for Resident 2's highest practicable physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that low air loss mattress (LAL -a medical-grade mattress that prevents and treats pressure ulcers [bedsores] by constantly blowing air through tiny holes in the fabric, keeping the patient's skin cool and dry) guidelines were adhered to for maximal effectiveness of the LAL mattress and resident comfort in accordance with the facility's policy and procedures (P&P) titled Low Air Loss Mattress revision date 11/2024, for one of one sampled residents (Resident 7). This deficient practice had the potential to significantly compromise Resident 7's safety, leading to serious skin breakdown, infection, increased discomfort and possibly hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to:1. Implement the recommendations of the facility's Registered Dietician (RD - a food and nutrition expert who has completed extensive training to help people manage their health through eating)according to the facility's policy and procedures (P&P) titled Assisted Nutrition and Hydration, dated 1/2025 when Registered Dieticians (RD - a food and nutrition expert who has completed extensive training to help people manage their health through eating) for one of three sampled residents (Resident 7). This deficient practice had the potential to cause worsening weigh loss and possibly hospitalization for Resident 7.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for supplemental oxygen (O2) administration for one of four sampled residents (Resident 25), the facility failed to : This deficiency had the potential for Resident 25 to experience undesired health effects related to the administration of oxygen not limited to hypoxia (a dangerous medical condition where body tissues or organs do not receive enough oxygen, potentially causing severe damage or death within minutes), hospitalization and death.

Inspectors wroteBased on observation and interview, the facility failed to implement Health insurance portability and Accountability Act (HIPAA - protect sensitive health information from being shared without knowledge or consent) and to provide care in a manner that promoted and enhanced the resident's quality of life, dignity, respect and individuality for and ensure that care for one of three sampled Residents (Resident 54) according to the facility's policy and procedure (P&P) titled Dignity and Respect, dated 1/2025. This deficient practice resulted in the violation of HIPPA and dignity rights for Resident 54.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two staff (Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1) practiced infection control standards according to the facility facility's policy and procedures (P&P) titled Standard Precautions, dated 12/2025 when:1. CNA 1 did not remove a gown (personal protective equipment-PPE) when exiting a resident's isolation room (a specialized, private room designed to separate a patient from others to control the spread of infections or protect vulnerable patients).2. LVN 1 did not disinfect (the process of using chemicals or physical agent to kill/destroy bacteria and other very small living things that cause disease) the blood pressure machine ( a device to monitor/check blood pressure) between residents. [...]

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to offer the influenza (flu) vaccine as required or appropriate to one of five sampled residents (Resident 38). This deficient practice placed Resident 38 increased risk of acquiring and transmitting the flu to other residents in the facility.

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to offer the Coronavirus Disease (COVID-19) vaccination to two of five sampled residents (Resident 2). This deficient practice placed Resident 2 at a higher risk of acquiring and transmitting the COVID-19 to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Certified Nurse's Aide (CNA) 3 reported the alleged violation of abuse to the facility Administrator (Admin) within 2 hours of receiving report of abuse allegation f for one of three sampled residents (Resident 1) according to facility policy and procedures titled, Reporting of Alleged Violations with a review date of 01/2025. This deficient practice of failing to report the alleged violation of abuse had the potential to result in delayed investigation by California Department of Public Health (CDPD) of the abuse in the facility and failure to protect Resident 1 from further abuse.

Inspectors wroteBased on interview and record review the facility failed to implement its abuse prevention program policy and procedure by failing to verify potential candidate's background check for a history of abuse, neglect, or mistreatment prior to the employee start working in the facility for one Certi ed Nursing Assistant (CNA 1). This failure had the potential for mistreatment, neglect, misappropriation of property, and abuse of residents.

Inspectors wroteBased on interview and record review, the facility failed to investigate allegations of sexual abuse (non-consensual sexual contact of any type or sexual harassment), for one of three sampled residents (Resident 3) and report to California Department of Public Health (CDPH), Ombudsman (a representative that helps families and residents in long-term care facilities by investigating and resolving complaints and serving as an advocate), and to the local law enforcement within 2 hours, failed to suspend the individual involved in the abuse allegations. This deficient practice had the potential to place other facility residents at risk for abuse, and delay required onsite inspection by CDPH. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise fall interventions to prevent repeated falls for one of four residents (Resident 1). Resident 1 was at risk for fall. As a result, Resident 1 suffered an unwitnessed fall on 6/07/2025 and was transferred to a general acute care hospital (GACH - a health facility having professional responsibility and an organized medical staff that provides 24-hour inpatient care) for further evaluation and care. The deficient practice also had the potential for Resident 1 to sustain serious injury and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy titled Abuse Prevention Program reviewed 8/2024, for one of two sampled residents (Resident 1), when on 4/8/2025 at 11:55 AM Resident 1 accused Certified Nursing Assistant 1 (CNA1) of sexual abuse (non-consensual sexual contact/touching of any type or sexual harassment), CNA1 was not immediately removed from providing direct care (including incontinent care) to residents and continued to have access Resident 1. As a result of this deficiency, Resident 1 was not protected from the potential of further harm or retaliation from CNA1 after being identified as a perpetrator.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report allegations sexual abuse (non-consensual sexual contact/touching of any type or sexual harassment), for one out of two sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse Investigation and Reporting reviewed 8/2024. By failing to report a sexual abuse allegation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 4/9/2025. This deficient practice had the potential to delay of an onsite inspection by the California Department of Public Health and law enforcement to ensure Resident 1's circumstance were investigated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Date the nasal canula (N/C- a plastic tube connected to an oxygen source that delivers 2-6 L/min of oxygen through prongs placed into each nostril) for two of four sampled residents, Residents 23 and 21 2. Date nebulizer (a medical device used to administer medication in the form of a mist inhaled into the lungs) tubing for Residents 23 and 21 3. Cover nebulizer mask after use for Residents 23 and 21 4. Date humidifier for Resident 23 These failures could have resulted in Resident 23 and Resident 21 acquiring an infection.

Inspectors wroteBased on observation, interview, and record review the facility's licensed nursing staff failed to ensure one out of 13 sample residents (Resident 20) received pain medication as prescribed by his physician by, failing to administer Resident 20's Aspercreme Lidocaine Patch 4% (a topical pain relief patch) for right knee pain as ordered by his physician. This deficient practice had the potential of causing unnecessary pain, mental anguish, and emotional distress by failing to attain or maintain Resident 20s highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and concurrent record review the facility failed to: 1. Maintain documentation and evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program; or 2. Present its QAPI plan to the Federal and/or State surveyors during recertification survey or upon request; or 3. Present QAPI evidence necessary to demonstrate compliance with these requirements; or 4. Develop, implement, and maintain an effective, comprehensive QAPI program, that addresses the full range of services the facility provides; or 5. Ensure governing body oversight of the facility's QAPI program and activities. Theses failures resulted in facility not having a comprehensive QAPI program and plan, disclosure of records and governance and leadership.

Inspectors wroteBased on interview and record review the facility failed to maintain effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement b failing to: 1. Conduct monthly and quarterly Quality Assurance and Performance Improvement (QAPI) meetings: 2. Provide proof for concerns related to how the facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, prioritizes improvement activities, implements corrective and preventive actions, and conducts performance improvement projects during QAPI meeting. [...]

Inspectors wroteBased on interview and concurrent record review, the facility failed to meet quarterly and receive reports from the Infection Prevention and on the Infection Preventionist Control Program This failure resulted in the Quality Assurance and Performance Improvement (QAPI) committee not in compliance with establishing performance and outcomes for quality of care and services delivered in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents, Resident 10, had a care plan for Schizophrenia (a mental illness that is characterized by disturbances in thought). This deficient practice placed Resident 10 at risk of receiving inappropriate care.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents, Resident 10, had care plans revised per policy and procedures titled Care Plans, Comprehensive Person-Centered. revised 3/2022. This deficient practice placed Resident 10 at risk of receiving inappropriate care.

Inspectors wroteBased on interview and record review for one of three sampled residents, Resident 1, the facility failed to notify the attending physician of x-ray results indicating a hip fracture in a timely manner. This deficient practice delayed Resident 1 to receive the definitive (medical treatment that goes beyond emergency care to maximize recovery) care to fix the fracture and had the potential to cause Resident 1 to experience pain longer than necessary.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician reviewed the monthly medication review recommendation from pharmacy for one of three sampled residents, Resident 14. This deficient practice placed Resident 14 at risk of receiving an unnecessary dose of antipsychotic (medication to treat mental health condition) medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one out of 13 sample residents (Resident 20) by failing to accurately document the administration of Aspercreme Lidocaine Patch 4% (a topical pain relief patch) for right knee pain in Resident's electronic medication administration records (eMAR) This deficient practice had the potential to negatively impact the delivery of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 11 out of the 20 resident rooms. The 11 Resident rooms consisted of 3 beds in each room. This deficient practice had the potential to result in inadequate useable living space, adequate space for the residents to safely move around, and working space for the nurses to care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the kitchen staff met the annual Inservice training sessions and evaluation requirements on fire prevention for 8 out of 8 Kitchen staff. This deficient practice had the potential for a knowledge, and training deficit among the kitchen staff, leading to inadequate or delayed response to the fire safety of the Residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents, (Resident 9), who was at risk for dehydration (lack of drinking sufficient fluids to meet the body's need) and malnutrition (food ingested [eaten]) does not provide enough nutrients or the right balance for optimal health), was offered sufficient food and did not experience unplanned severe weight (wt) loss (a body weight loss of greater than five [5] percent [% - unit of measure] in one month). The facility failed to: 1. Identify interventions related to Resident 9's poor food intake since admission to prevent progressive wt loss. 2. Monitor and document Resident 9's high protein nutrition (HPN - supplement nutritional drink with high protein) intake to determine Resident 9's intake met his nutritional needs. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory treatment and care for one of 16 sampled residents (Resident 13), who had chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing-related problems) and history of pneumonia (a serious infection of one or both lungs in which the air sacs fill with pus and other liquid). The facility failed to: 1. Closely monitor Resident 13's respiratory condition, including response to treatment after being identified to have a change of condition (COC, a sudden clinically important deviation from a patient's baseline) when Resident 13 develop a cough on 3/20/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure eight of 16 sampled residents (Resident 1, 9, 21, 23, 24, 25, 189, and 190) had Advanced Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record. This deficient practice had the potential for Resident 1, 9, 21, 23, 24, 25, 189, and 190 to be denied the right to request or refuse medical care and treatment.

Inspectors wrote2a. A review of Resident 9's admission Record indicated Resident 9 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including unspecified severe protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients] in the body), type 2 DM, and recurrent depressive disorder (when a person has experienced depressive symptoms for most of the day, for more days than not over two years). A review of Resident 9's MDS dated [DATE], indicated that Resident 9 had a severely impaired cognition (ability to think and make decisions) and required maximal assistance from staff for mobility such as rolling left to right, sit to lying, sit to stand, and toilet transfer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident's individual assessed needs for six of 16 sampled residents (Resident 9, 13, 21, 31, 37, and 189) by failing to: 1. Develop a comprehensive care plan when resident had a change of condition for Residents 31 and 13. 2. Develop a comprehensive care plan for the use of bed side rails for Residents 9, 21, and 189. 3. Develop and implement comfort measure (treatments used to ease pain and distress when life-prolonging options are not available) care plan for Resident 37. These deficient practices had the potential to result negative impact on the health and safety, and the quality of care and services provided to Residents 9, 13, 21, 31, 37, and 189.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards in preventing avoidable accidents to one of five sampled residents (Resident 3) by failing to ensure Resident 3's medications were not left unattended at bedside during medication pass. This deficient practice had the potential to result in an unsafe medication administration to Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had the appropriate competencies to provide nursing and related services to assure safety of the residents by failing to: 1. Maintain and update basic life support/Cardiopulmonary Resuscitation (BLS/CPR) certification for two of seven sampled facility staff (Licensed Vocational Nurse 2 [LVN 2] and Certified Nursing Assistant 5 [CNA 5]). 2. Ensure Licensed Vocational Nurse 5 (LVN 5) had the specific competencies and skills sets necessary to perform safe medication administration for Resident 15. This deficient practice had the potential to place resident at risk of not getting proper immediate care in a life-threatening situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 3/23/24 when: 1. [NAME] used small scoop size to serve Baked Ziti (pasta with tomato and cheese sauce baked and topped with breadcrumbs) for five residents on mechanical soft finely chopped (Ground) diet (consists of foods that are moist, ground, chopped or easily mashed required little chewing) while five residents were mechanical soft finely chopped diet received ½ cup of Baked Ziti instead of 1 cup. 2. 17 Residents on mechanical soft diet (ground and chopped) did not receive garlic toast bread texture in form that met their needs when they received garlic toast without additional 1-2 tsp (teaspoons) of margarine to adequately moisten the bread. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. One large bowl of vanilla flavored pudding was stored on the same shelf next to raw shelled eggs and three (3) cartons of raw liquid eggs. 2. One small cup stored inside dried chicken base powder container and the cup in contact with the powdered chicken base. 3. Three (3) large containers of Vanilla flavored nutrition supplement with manufactured instruction to use within 3 days once opened were stored in the refrigerator with open dates of 1/23/24, 2/17/24, 2/21/24 exceeding safe storage period for the nutritional supplements. 4. Ice machine was not maintained in sanitary manner and the inside compartment of the ice machine was observed having gray and orange color residue. 5. [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate medical record in accordance with accepted professional standards and practices for eight of 16 sampled residents (Resident 1, 9, 21, 23, 24, 25, 189, and 190) by failing to ensure advance directive acknowledgment forms were easily accessible via residents' medical charts. These deficient practices had the potential to negatively impact the delivery of service given to Resident 1, 9, 21, 23, 24, 25, 189, and 190.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted or enhanced resident's dignity and respect by failing to ensure staff was not standing over resident while eating for one of seven sampled residents (Resident 90). This deficient practice had the potential to cause psychosocial harm and can resident's right to be treated with dignity for Resident 90.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for two of 16 sampled residents (Resident 30 and Resident 190) by: a. Failing to ensure Resident 30's preferences on preferences on daily activities. b. Failing to ensure Resident 190's bed and mattress was appropriate for Resident 190's height. This deficient practice had the potential to negatively impact the psychosocial well-being of the residents and may cause physical harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure protection of resident's medical record for one of three sampled resident (Resident 21). This deficient practice had the potential to violate Resident 21's right to privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy regarding reporting of an unusual occurrence and injury of unknown source and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of one sampled resident (Resident 26). This resulted in a delay of an onsite inspection by the Department to ensure the safety of the residents and had the potential to place residents at further risk for injuries.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy regarding reporting of an unusual occurrence and injury of unknown source within 24 hours in accordance with state or federal law for one of one sampled resident (Resident 26). This resulted in a delay of an onsite inspection by the State Agency to ensure the safety of the residents and had the potential to place residents at further risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventive care consistent with professional standards of practice to two of two sampled residents (Residents 9 and 21), who was at risk for development of pressure injuries, by failing to: 1. Ensure low air loss mattress (LALM-a mattress designed to prevent and treat pressure wounds) was functioning and was not turned off when Resident 9 was in bed. 2. Ensure the appropriate setting of the LALM was properly set up according to physician's order (MD order) for Resident 21. These deficient practices can place Residents 9 and 21 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident receives appropriate treatment and services to increase, prevent, or maintain the range of motion (ROM- the extent of movement of a joint) mobility for one of three sampled resident (Resident 190). This deficient practice had the potential to place Resident 190 at risk for further ROM decline and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a visible and prominent place daily the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for three of three sampled days (3/23/2024, 3/24/2024, and 3/25/2024). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Pharmaceutical services included procedures to ensure the medications used from the emergency kit (e-kit - secured container or secured electronic system containing drugs which are used for either immediate administration to residents or in an emergency or as a starter dose) located in Medication room [ROOM NUMBER] were ordered and replaced as soon as possible per facility's policy. 2. Ensure professional standards of practice for medication administration were used when administering medications to 1 out of 16 sampled residents (Resident 15). [...]

Inspectors wroteBased on interview and record review, the facility failed to do a Gradual Dose Reduction (GDR, an attempt to decrease or discontinue psychotropic [acting on the mind] medication after no more than three months from the start date of the psychotropic medication, unless clinically contraindicated) for 2 of 16 sampled residents (Residents 10 and 21). These deficient practices had the potential to result in overuse of an antipsychotic medication, without monitoring for the effectiveness and/or ineffective of the medication and can lead to adverse (negative) drug reactions.

Inspectors wroteBased on observations and record reviews, the facility failed to staff did not crush medications together for five of 31 opportunities during medication administration for one of 16 sampled residents (Resident 15). This deficient practice resulted in medication error of 16 percent (%). Mmedication error rate should be less than 5%.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 34's) Levalbuterol hydrochloride (HCL) (Xopenex-medication being given via inhalation [inhaling medication in the form of gas or vapor] used to treat or prevent bronchospasm [when muscles that line the airways in the lungs becomes tighten) Nebulizer was disposed of within two weeks after opening per manufacturer's policy. This deficient practice had the potential to compromise the safety and effectiveness of medication, resulting in medication errors when administered to Resident 34, and placed the resident at risk for respiratory difficulty.

Inspectors wroteBased on interview and record review, the facility failed to update the Facility Assessment (FA) annually to reflect staffing plan to meet the resident care needs by ensuring that Activity Director (AD) and Social Service Director (SSD) were included in the facility's staffing plan. This deficient practice may result in the facility failure to identify specific factors that would require a change to the assessment and had the potential to affect the resident care and decline in quality of care.

Inspectors wroteBased on interview, and record review, for two of 16 sampled residents (Residents 34 and 139), the facility failed to: 1. Implement its protocol for antibiotic (a substance used to kill bacteria and to treat infections) use. 2. Monitor actual antibiotic use by failing to initiate a surveillance log These deficient practices had the potential for Residents 34 and 139 to develop resistance (not effective to treat infection) to antibiotics from unnecessary and inappropriate antibiotic use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 10 out of 20 resident rooms met the square footage requirement of 80 square feet (sq. ft.) per resident. This deficient practice had the potential to result in inadequate useable and safe living space for the residents to move freely and for nursing staff to provide care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional care and services to one of two sample residents (Resident 2) by failing to ensure implementation and modification of interventions consistent with Resident 2 ' s needs and goals per registered dietitian (RD) recommendations. This deficient practice placed Resident 2 at risk for further weight loss.

Inspectors wroteBased on interview and record review, the facility failed to maintain the fire alarm system (system of devices that detects the presence of fire and alerts the appropriate agencies when the system is triggered) protecting 40 out of 40 residents in the facility in good working condition such that the fire alarm system does not send false alarms. This deficient practice has the potential for the facility to not respond to a true alarm of an active fire, or for facility staff to experience alarm fatigue (when signals activate so often that staff ignore or actively silence them) which may contribute to the spread of a fire during a true fire emergency affecting the safety of residents, staff, and visitors to the facility.