Walnut Creek Skilled Nursing & Rehabilitation Cent

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of two sampled residents (Resident 1) who received enteral nutrition via PEG (Percutaneous Endoscopic Gastrostomy, a flexible feeding tube inserted through the abdomen directly into the stomach. It provides nutrition, fluids, and medications for individuals who cannot eat or swallow by mouth, also referred to as g-tube) tube was provided care and services in accordance with physician orders and accepted standards of practice when:- Resident 1's head of bed (HOB) was not elevated during feeding as required.- The g-tube placement was not measured prior to administration of feeding and medications.- Dressing-change order for the PEG-tube site was not followed. This failure placed Resident 1 at risk for complications including infection at the tube site and aspiration during feeding.

Inspectors wroteBased on observation, interview, and record review, facility failed to maintain complete and accurate medical records for three out of four (Residents 1, 2, and 3) reviewed residents. This failure had the potential to lead to incorrect monitoring for residents in the behavioral health unit, potentially leading to harm. During a review of facility's document titled, admission Record, for Resident 1, printed 5/19/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder (a mental health condition that is marked by a mix of symptoms, including hallucinations and delusions and mood disorder symptoms). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for two out of four sampled residents (Residents 1 and 3). This failure had the potential to result in incorrect or delayed monitoring interventions, miscommunication among staff, and increased risk of harm for residents requiring enhanced behavioral safety supervision. During a review of facility's document titled, admission Record, for Resident 1, printed 5/19/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder (a mental health condition marked by a mix of symptoms including hallucinations, delusions, and mood disorders, such as depression or mania). During an interview on 5/19/26 at 4:30 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain daily weights as ordered by the physician for one of four sampled residents (Resident 4). This failure had the potential to lead to fluid overload (a condition where there is too much fluid in the body) in a patient with heart failure (a condition where the heart cannot pump enough blood to meet the body's needs) which could result in Resident 4 needing to be readmitted to the hospital. During a record review of facility's document titled, admission Record, printed 5/22/26, for Resident 4, Resident 4 was admitted to the facility on [DATE] with multiple diagnoses including heart failure, fluid overload (a condition where there is too much fluid in the body) and localized edema (swelling caused by excess fluid trapped in the body's tissues). During a concurrent interview and record review on 5/19/26 at 3:35 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident 1 was treated with dignity and respect when staff placed a timer on the resident's table to indicate the duration of feeding and repositioning. This failure created pressure on Resident 1, making the resident feel rushed during meals, which had the potential to compromise Resident1's dignity and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary activities of daily living (ADL) care for one dependent resident (Resident 2) when Resident 2's face appeared oily, crust-like matter was stuck between the eyelids, and pale, white-color dry matter was noted on the mouth and teeth. Failure to provide grooming and personal hygiene has the potential to affect the resident's physical and psychosocial comfort and wellbeing and could also place the resident at risk for aspiration and infection.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was not charged for services covered by Medicare when the facility repeatedly billed Resident 1 and/or Resident Representative (RR) for an extended stay at the facility. This failure resulted in unnecessary billing, inconvenience and potential for emotional distress to RR. [...]

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to notify Resident 1 and/or Resident Representative (RR) of potential financial liability for an extended stay when the payer source changed to private pay. This failure had the potential to result in uninformed decisions about care, and emotional distress due to unnecessary financial liability. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Residents 148, 68, 109, 133, and 140) were provided a clean, sanitary and homelike environment when whitish grime, stains and dried matter were sticking on the surroundings of Residents 148, 68, 109, 133, and 140's mattresses. These failures had the potential to cause discomfort, emotional distress, and spread of disease-causing organisms to Residents 148, 68, 109, 133, and 140.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two out of 31 (Residents 138 and 49), were routinely given pain medications without clarification of physician's order and adequate indications. For Resident 138, he was regularly given Norco oral tablet (medication used to treat moderate to severe pain) 5-325 milligram (mg) tablet to be administered one tablet three times a day, and Tylenol Extra Strength oral tablet (medication used to treat minor pain and fever reducer) 500 mg tablet to be administered one tablet two times a day. For Resident 49, was regularly given Acetaminophen 325 mg tablet to be administered two tablets via gastric tube (g-tube - surgically tube placed through the abdominal wall used to administer fluid, nutrition, and medication) two times a day. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when Facility [NAME] (FC) touched ready-to-eat food on multiple plates with the same gloved hand that was used to hold oven handles. This failure had the potential to result in cross-contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility did not respect the right to maintain personal belongings securely for one of 18 sampled residents (Resident 53) when Resident 53's transfer sling, wheel chair and shoes had been missing. This created unnecessary distress for Resident 53's family.

Inspectors wroteBased on interview and record review, for one of four sampled residents (Resident 23) who were transferred to the hospital for acute care, the facility failed to notify Resident Representative (RR) 2 when Resident 23 vomited on 4/5/25. Resident 23's condition worsened and was transferred to the hospital the same day for fever and weakness. This failure had the potential to result in delayed interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 60 and Resident 142) received necessary care to maintain good grooming and personal hygiene when Resident 60 and Resident 142 had long fingernails. This failure resulted in Residents 60 and Resident 142 at risk for skin irritation and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion when Restorative Nursing Assistant (RNA) services ( RNA program, focuses on nursing interventions that help residents in long-term care maintain or regain their ability to perform activities of daily living (ADLs) and improve their overall well-being) to three of four sampled residents (Residents 60, 120 and 126) who were reviewed for range of motion/mobility needs, as indicated in the physician orders and comprehensive care plan. This failure had the potential to result in further decline in range of motion.

Inspectors wroteBased on observation, interview, and record reviews, the facility did not provide immediate necessary care and investigate potential self-harm for two of 18 sampled residents (Residents 101 and 210). Staff did not implement safety measures when Residents 101 and 210 expressed feeling suicidal. Staff did not investigate the cause of Resident 210's wrist wound. These failures have the potential to not ensure the residents' safety and/or promote and maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their infection prevention and control program for two of three sampled residents (Residents 125 and Resident 46) when two staff members did not wear appropriate Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury and to prevent the transmission of infectious agents from one person to another, also known as cross-contamination) while providing care to Resident 125 and Resident 46, who were placed on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). This failure had the potential to result in spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 1 had privacy during care when staff transferred Resident 1, who was not wearing clothes and uncontrollably yelling fuck repeatedly, from a shower chair into his room without adequately covering his genitals. This failure had the potential for psychosocial harm when Resident 1 ' s genitals were exposed and viewable to anyone in the hallway when Resident 1 was being transferred from the shower chair into the room and was yelling uncontrollably.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure medications were administered as ordered by the physician, for one of three sampled residents (Resident 1) when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. This failure resulted in Resident 1 not getting medication to treat his low blood pressure (BP) and potential return of symptoms to manage low blood pressure such as dizziness, lightheadedness, fainting spells, including decrease or limitation in Resident 1's activities of daily function, participation in his physical therapy treatment care, increased fall risk, injury and possible hospitalization.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) received medications as ordered by the physician and was free of significant medication error (one which cause the resident discomfort or jeopardizes his or her health and safety), when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident's right to choose health care and providers of health care services was honored for one of three sampled residents (Resident 3), when Registered Nurse (RN) 1 proceeded to administer medications to Resident 3, after Resident 3 had already refused to receive care from RN 1. This failure resulted in emotional distress for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure to meet the interests of and support the physical, mental, and psychosocial well-being of one of three sample selected residents (Resident 1), when Resident 1 was not able to be out of her bed due to Mechanical Lifting Device (MLD) sling (a flexible strap or belt used in the form of a loop to support or raise a weight) not being available at the facility. This failure resulted in Resident 1 staying in her bed for two days and possibility of developing pressure ulcer and mental health issues.

Inspectors wroteBased on interview and record review, the facility failed to manage pain for one out of four sampled residents (Resident 1), when Resident 1 did not received pain medication as desired for 13 hours. This failure resulted in Resident 1 suffering from severe pain and a feeling of neglect.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide emergency basic life support, including Cardiopulmonary Resuscitation (CPR, any medical intervention used to restore blood circulation or breathing functions that have ceased) to Resident 1 who was found with no pulse and no spontaneous respiration. This failure resulted in the delayed provision of emergency basic life support for Resident 1. Resident 1 was pronounced deceased by emergency personnel at 5:52 a.m., 42 minutes after Resident 1 was found with no pulse.

Inspectors wroteBased on interviews and record review the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) was treated with dignity and respect when Resident 1, who is dependent on staff for eating, was not aided with eating during the candlelight dinner. This deficient practice negatively impacted Resident 1's sense of self-worth and self-esteem and made her feel neglected and left out.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) received assistance with Activities of Daily Living (ADLs, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) when the assigned Certified Nursing Assistant (CNA) did not help Resident 1 in a timely manner. This failure resulted in Resident 1 waiting for a long time for ADL care and her urinary catheter bag (container or collector for the urine as it leaves the body and passes through the catheter tube) overflowing and soaking her wet in the wheelchair compromising Resident 1's dignity and comfort.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit the quarterly and annual comprehensive Minimum Data Set (MDS, an assessment tool) assessments for 13 of 13 sampled residents. This failure placed residents at risk for not being assessed in a timely manner resulting in potential for inappropriate care planning and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive-centered care plans for four of 31 sampled residents (Resident 120, Resident 12, Resident 69, Resident 219) when: 1. The facility did not develop an individualized care plan that includes current treatment, preventive measures, and services to manage Resident 120's deep tissue injury. 2. The facility did not monitor Resident 12's urine output according to the care plan. 3. The facility did not implement a care plan for Resident 69's diabetes. 4. The facility did not implement a care plan for Resident 219's antipsychotic medication. This failure had the potential for each resident to not have their specific needs met and result in inappropriate and inaccurate provision of care that could negatively impact the quality of care and services.

Inspectors wrote3. During a review of Resident 24's undated Face Sheet, the Face Sheet indicated Resident 24 was admitted in the facility on 1/2011 with diagnoses that included dementia (memory loss which can interfere with activities of daily living). During a review of Resident 24's MDS, dated [DATE], the assessment indicated Resident 24 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a record review of Resident 24's ADL Care Plan, dated 4/28/23, the care plan indicated Resident 24 had a self-care performance deficit related to dementia. The care plan indicated for staff to check nail length and trim and clean on bath day and as necessary and report any changes to the nurse. During a concurrent observation and interview on 1/22/24 at 12:48 p.m. with CNA 5, Resident 24 was sitting in bed and eating lunch. [...]

Inspectors wroteBased on observation, interview, and record review, for two of three sampled residents reviewed for catheter care, the facility failed to; provide appropriate care and services to prevent urinary tract infections (UTI) when: 1. Resident 12's urinary output from nephrostomy tube (a small tube that helps drain urine from the kidneys) was not consistently monitored and documented per physician's order. This failure had the potential to result in urinary tract infections. 2. Resident 160's urine sample was not collected per physician's order. This failure resulted in delayed intervention that could potentially lead to worsening urinary tract infection symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was sufficient licensed nursing staff, leading to late administration of high-risk medications for four of four sampled residents (Resident 93, 2, 72, 77). The late administration of medications included medications to manage high blood pressure, seizures, and pain. This failure resulted in Resident 93 to experience severe pain; and placed Resident 2 at risk for seizures; and Resident 72 and 77 at risk for high blood pressure.

Inspectors wroteBased on interview and record review, for three of six sampled residents (Resident 51, Resident 69, and Resident 93), the facility: 1. Failed to ensure monthly drug regimen for Resident 51, Resident 69 and Resident 93 were reviewed monthly. 2. Failed to ensure Consultant Pharmacist recommendation was acted upon for Resident 93. These failures had the potential to result in unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date, when multiple expired medications and multiple medications for discharged residents were found together with non-expired, active medications for other residents on the same shelf. This failure had the potential to result in using expired medications for the residents and medications for discharged residents would be taken by the staff for personal advantage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in the kitchen when: 1. Conveyor Toaster was not clean. 2. Floor underneath the wire shelf and staff's personal locker in dry storage room contained food debris, and dust. 3. Expired test strip was used to test sanitizer concentration for the dish machine. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 147 of 153 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's appearance was in a manner to maintain dignity and self-esteem for one of one sampled resident (Resident 24) when Resident 24 was observed with long facial hair. This failure had the potential to result in Resident 24 not feeling good about herself and low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure the family representative (FR) was informed of a significant change in condition for one of one sampled resident (Resident 138) when Resident 138 had a significant weight loss of 13.68% in six months from 7/2023 until 1/2024. This failure resulted in FR to be unaware of Resident 138's condition and not being able to participate in her plan of care.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 8), the facility failed to develop and implement written polices and procedures that included re-training and re-education of staff who was accused of abuse before returning to work with residents. This failure had the potential to result in exposing vulnerable residents to abuse.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) assessment for one of four sampled residents (Resident 121) to reflect the accurate medical diagnosis. This failure placed Resident 121 at risk to not receive care and services appropriate to his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 156) had skin assessments completed for the bilateral arm skin discolorations. This failure had the potential to result in ineffective monitoring and ineffective plan of care and treatment of the skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a therapeutic diet to one of one sampled resident (Resident 138) when they did not follow the physician's order. This failure had the potential to contribute to continued, unplanned weight loss for Resident 138.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the scheduled pain medication was provided for one of one sampled resident (Resident 93) in a timely manner. Resident 93 did not receive one tablet of Percocet (a controlled medication to treat moderate to moderately severe pain) 5/325 milligrams (mg) until four hours later from the scheduled time. This failure resulted in Resident 93 to experience nine (severe pain) out of 10 pain in his lower back.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 51), the facility failed to ensure Resident 51 was free from unnecessary drugs when amoxicillin (antibiotic, treats infection) was administered without adequate monitoring for side effects. This failure had the potential to result in delayed management of adverse effects from the medication.

Inspectors wroteBased on observation, interview, and record review, for one of five sampled residents (Resident 219) reviewed for unnecessary medications, the facility failed to ensure psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications were administered for specific condition as diagnosed and documented in the clinical record. Resident 219 was administered ziprasidone (treats schizophrenia and bipolar disorder, types of mental illnesses) without a specific indication and was administered fluoxetine, mirtazapine, and trazodone (all anti-depressants) for the same indication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure related to food brought from the outside to one of five sampled residents. Residents' food refrigerator had expired food that was not discarded. This failure had the potential to expose the facility's residents to unsafe food storage practices which could lead to foodborne illness (food poisoning).

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 8), the facility failed to ensure Resident 8 was protected from further potential abuse when Certified Nursing Assistant (CNA) 7, who was the alleged abuser, continued to work in resident care areas, with access to Resident 8 and other residents after an abuse allegation was reported. This failure had the potential to result in retaliation and further occurrences of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services consistent with professional standards for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4), when: 1. Respiratory Therapy Consultant (RTC) changed Resident 1's tracheostomy tube with an incorrect tube type and size. (Tracheostomy, also used interchangeably with trach or Tracheotomy is a surgical opening created through the neck into the trachea [windpipe] to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is placed through this opening to provide an airway and to remove secretions from the lungs. A patient breathes through this tube rather than through the nose and mouth). This failure potentially contributed to Resident 1 going into respiratory distress. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure complete documentation of medical records for one of three residents (Resident 1) involving: 1. missing seven weekly skin reports 2. missing twenty-six ADL (activities of daily living) entries This failure resulted in Resident 1 having incomplete medical records which potentially may affect Resident 1 ' s care and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure showers were provided to maintain grooming and personal hygiene for one of two sampled residents (Resident 2), who was totally dependent on staff for Activities of Daily Living (ADLs, such as transfers from bed to chair, bathing/showers, eating, personal hygiene). This failure had the potential to result in poor grooming and personal hygiene and potentially result in skin irritation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services for one of two sampled residents (Resident 1) when transportation going to and from dialysis treatments was not provided. Resident 1 went to the dialysis center with a staff member pushing Resident 1 in a wheelchair. This failure had the potential to result in an avoidable accident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) care plans were reviewed and revised by the interdisciplinary team after each assessment when Resident 1 had multiple new wounds at the facility and the facility did not start a new care plan nor update the existing care plan for skin damage prevention for Resident 1. This failure resulted in repeated skin damage and new wounds for Resident 1 at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from accidents while residing at the facility, when Resident 1 had a skin tear to his right hand while being transferred to the shower. This failure resulted in Resident 1 had a skin damage, bleeding, and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure, all drugs and biologicals were stored in locked compartments for one of three sampled residents (Resident 1), when medication was found at Resident 1 ' s bedside unattended. This failure had a potential in Resident 1 not receiving the medication in the right dose and right time.

Inspectors wroteBased on interview and record review, for one of one sampled residents (Resident 1), the facility failed to provide a bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) notice to Resident 1 or Resident 1's Representative (RR) during transfer to the hospital. This failure had resulted in violation of Resident 1's right to return to his previously assigned bed.

Inspectors wroteBased on interview and record review, the facility failed to allow one of one sampled resident (Resident 1), to return to the facility when Resident 1 was discharged from the hospital on [DATE]. This failure resulted in an unnecessary hospital stay. As of 12/22/23 (37 days), Resident 1 continued to stay at the hospital pending the facility's approval to return.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide three showers per week as ordered by physician for one of two residents (Resident 1). This failure resulted in Resident 1's inability to exercise his rights in how he receives care causing emotional distress.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care in skilled nursing facilities) was completed within 14 calendar days for five of five sampled residents (Residents 110, 105, 108, 109, and 107). This failure resulted in delayed completion and submission of Residents 110, 105, 108, 109 and 107's MDS assessments, and had the potential to result in delay of care plan development and implementation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assist one (Resident 14) of one sampled resident with insertion of hearing aids. This failure resulted in Resident 14 not being able to use her hearing aids and feeling anxious and upset from difficulty hearing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served under sanitary conditions when: 1. The Dry Storage Room had two full cases of apple juice on the shelf 45 days past the used-by-date. 2. The Reach-in refrigerator had five glasses of individually served drinks and two food items in small individually served containers one day past the used-by-dates. 3. The kitchen work area had seven boxes of juice. The boxes had been opened and had dispensing nozzles with attached tubing; the tubing was full of liquid; the boxes were not labeled with date of opening or used-by date. These failures had the potential to result in food-borne illness for residents consuming the products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the responsible party for three days of a change in the skin condition of one (Resident 56) of 27 sampled residents. The failure to notify Resident 56's responsible party of the development of a bluish discoloration on Resident 56's right wrist prevented RP from being informed about Resident 56's total health condition, and any possible treatment or care options.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet the needs of one (Resident 119) of nine residents when Resident 119 received half of the prescribed dosage for furosemide (medication used to increase urination and decrease body fluids to decrease the workload on the heart), and metformin (medication used to decrease blood sugar levels). This failure had the potential to result in inadequate treatment of Resident 119's medical conditions, and lead to complications of heart failure (the heart does not pump enough blood to meet the body's needs), and diabetes (a condition of unstable blood sugar levels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment when staff did not perform hand hygiene between glove changes when administering medication to Resident 52. This failure had the potential for infection of Resident 52.