West Hills Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was assessed as clinically appropriate to self-administer medications, had a physician's order to self-administer or store medications at bedside prior to self-administering or storing medications at bedside, and demonstrated the ability to safely and securely store medications for one of seven sampled residents (Resident 2). This deficient practice had the potential for other residents to access and ingest the medications, which could result in serious health complications and had the potential to result in unsafe medication administration or omission (the act of not including something that should have been included) for Resident 2.

Inspectors wroteBased on interview and record review the facility failed to ensure that a physician's stat (immediate) order for an X-radiation (x-ray - a type of medical imaging that uses radiation to take pictures of the inside of the body) was completed timely for one of four sampled residents (Resident 2), following Resident 2's fall, in accordance with the facility's policy and procedure (P&P), titled Stat Orders, last reviewed on 1/8/2025 which indicated that stat orders are to be completed promptly within a four to six-hour time frame. This deficient practice had the potential for delay of treatment and services to Resident 2 following the resident's fall.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) on abuse for an allegation of sexual abuse for one of two sampled residents (Resident 1) by failing to: 1. Conduct a thorough investigation into alleged sexual abuse.2. Complete and submit a written five (5) day follow-up investigation report indicating the results of an investigation for the allegation of sexual abuse that occurred on 12/18/2025. This deficient practice had the potential to place Resident 1 at risk for further sexual exploitation and resulted in a delay in the investigation of a suspicion of sexual abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures (P&P) to ensure the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of sexual abuse for one of two sampled residents (Resident 1) to the State Survey Agency (SSA) within the required timeframe. This deficient practice had the potential to place Resident 1 at risk for further sexual exploitation and resulted in a delay in the investigation of a suspicion of sexual abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy titled In-service Training, All Staff, by failing to provide in-service training (training intended for those actively engaged in a profession or activity) on behavioral health to all staff, as scheduled on the facility's in-service calendar. This deficient practice had the potential to place residents who have a behavioral health diagnosis at risk for not receiving the necessary care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift was posted daily (on 12/18/2025 and 12/22/2025) as indicated in the facility's policy and procedure titled, Direct Care Daily Staff Numbers. As a result, the total number of staff and the actual hours worked by the staff in the facility was not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were identified as a candidate for scheduled toileting (a structured approach aimed at helping individuals manage their bladder [organ that stores urine] control by prompting them to use the toilet at regular intervals), participated in a toileting retraining plan in accordance with facility policy and the physician's order for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 not to attain Resident 1's highest functional level. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of two sampled resident's (Resident 1) Responsible Party (RP) of a change in condition (any significant alteration in a resident's usual health status) when on 11/22/2025 Resident 1 was diagnosed with shingles (painful skin rash that usually appears on one side of the body or face). This deficient practice had the potential to place residents at risk for unmet care needs and compromised continuity of care and could have resulted in a negative impact on Resident 1's treatment if decisions regarding care had been required at the time of the change of condition. [...]

Inspectors wroteBased on interview and record reviewed, the facility failed to implement the facility's infection control policies by failing to implement contact isolation precautions (precautions implement for individuals known or suspected to be infected with microorganisms that can be transmitted by direct contact) for one of two sampled residents when on 11/22/2025, Resident 1 was not placed on contact isolation precautions after being diagnosed with shingles (painful skin rash that usually appears on one side of the body or face). This deficient practice had the potential for the spread of shingles among residents and staff in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were not standing over a resident while assisting with feeding for one of three sampled residents (Resident 1). This deficient practice had the potential to affect Resident 1's self-esteem, self-worth and sense of independence.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempts were made to resolve the grievance for one of three sampled residents (Resident 1). This deficient practice violated Resident 1's' right to have his grievance addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) received services and treatment for pain management by failing to obtain pain medication orders appropriate for Resident 1's pain level. This deficient practice had the potential to result in inadequate management of Resident 1's pain.

Inspectors wroteBased on interview and record review, the facility failed to submit a new corrected and accurate Level 1 Preadmission Screening and Resident Review (PASARR- an assessment to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of four sampled residents (Resident 2). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge was provided to two of three sampled residents (Resident 1, who had severely impaired cognition [the mental action or process of acquiring knowledge and understanding through thought, experience and the senses], lacked capacity to understand and make decisions, and required staff assistance for all Activities of Daily Living [ADL - basic tasks that individuals perform to maintain their daily lives] and Resident 2, who also required staff assistance for all ADLs) by failing to:1. Ensure that the post-discharge destination and continuing care provider were capable of meeting the needs of Resident 1 and Resident 2 prior to discharge. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were not standing over a resident while assisting with feeding for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the resident's self-esteem, self-worth, and sense of independence. During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted the resident on 7/25/2024 with diagnoses including anoxic brain damage (when the brain is deprived of oxygen entirely, leading to the death of brain cells and potential permanent damage after just a few minutes), epileptic seizure (a sudden, abnormal surge of electrical activity in the brain that can cause temporary changes in movement, behavior, sensations, or awareness), and dysphagia, oral phase (difficulty swallowing that originates in the mouth). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by:1. Failing to administer Resident 1's doxycycline monohydrate (antibiotic used to treat a wide range of bacterial infections), mirtazapine (medication used to treat depression [a mood disorder characterized by a persistent feeling of sadness and loss of interest in activities, which significantly impacts daily life]), atorvastatin (lowers cholesterol and triglyceride [fats] levels in the blood), and omeprazole (medication used to reduce the amount of acid produced by the stomach) as prescribed by the physician. This deficient practice resulted in the omission of medications which could have resulted in severe health complications.2. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and service facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) by failing to:1. Address which medications Resident 15 is to take when she is out on pass and what kind of monitoring is conducted before taking them for one of five residents investigated for receiving unnecessary medications. This had the potential for Resident 15 to not receive the due medications or to have side effects such as dizziness and fainting from not monitoring blood pressure before administering. 2. Address Resident 86`s oxygen use. [...]

Inspectors wrote1. Ensure a resident`s representative or responsible party (RP) was included during the Interdisciplinary (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) care plan (a document that summarizes a resident's needs, goals, and care/treatment) meeting for two of two residents (Resident 5 and 12) reviewed under the care area Care Planning. This deficient practice had the potential to result in failure to deliver the necessary care and services. 2. Update and revise a resident`s care plan after the physician discontinued the administration of apixaban (a medication that prevents blood clots [gel-like clumps of blood] from forming and treats the existing ones) for one of five sampled residents (Resident 2) reviewed under Anticoagulant (medications that prevent or reduce blood clotting) care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Residents 2, 6, and 13) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to:1. For Resident 13, provide an orthotics (an external device to support, align, or correct a movable part of the body) assessment and training during Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) treatment prior to starting an Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) to wear a right hand orthosis for up to six hours seven days a week.2. [...]

Inspectors wroteNumber of residents sampled:Number of residents cited: 1Resident 14 missed multiple days at the dialysis center.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when curry chicken portions were two (2) ounces (oz, a unit of measurement) instead of three (3) oz portions. This failure had the potential to decrease nutrient intake of protein resulting in unplanned weight loss to 77 of 140 residents on regular texture (texture of food with no restrictions and modifications) diet getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserve flavor and appearance when the fiesta salad was watery, and dressing did not taste like Italian dressing. This deficient practice placed 77 of 140 facility residents on regular texture diet (texture of food with no modifications and restrictions) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. The tub of jelly was not labeled and dated. The egg salad was not labeled with expiration or discard date.2. Kitchen equipment and kitchen areas were not cleaned and sanitized.a. The walk-in refrigerator vent had dust and dirt buildup and residues.b. The reach-in freezer had dry ice cream spill.c. Lentils were on the floor of the dry storage room.d. The food weighing scale had dust buildup.e. Scoop and utensils drawer and pots and pans dry storage areas had food dry spills, crumbs, food particles and dust.f. Stainless steel food preparation area had salt residues, grey and black dirt buildup. 3. Three (3) of 3 dented cans were stored with non-dented cans.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when one (1) of two (2) dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) was propped (to keep something from closing by placing something underneath) open while not actively being used. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 136 of 140 facility residents.

Inspectors wroteBased on interview and record review the facility failed to establish and implement a policy and procedure regarding transportation to dialysis from the facility when one (Resident 14) of two sampled residents investigated for dialysis missed their dialysis treatments multiple times in the month of 5/2025. As a result, Resident 14 was transferred three times to a general acute care center (GACH, or simply hospital) for the dialysis treatment to be completed. By not having a policy regarding transportation to dialysis, other residents on dialysis have the potential for not receiving their dialysis treatments.

Inspectors wroteBased on interview and record review, the facility failed to maintain timely and accurate resident medical records in accordance with accepted professional standards for three of seven sampled residents (Residents 2, 4, and 6) by failing to:1. For Resident 4, obtain a complete and accurate informed consent (agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to applying physical restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body). This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services for Resident 4.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices by failing to:1. Ensure a resident`s urinal was not hung on the trash bin for one of two sampled residents (Resident 45). This deficient practice had the potential to result in contamination (making something dirty) of the resident's care equipment and risk of transmission of bacteria. 2. Ensure the nasal cannula was not touching the floor and the urinal was labeled for one of residents (Resident 34) during an initial pool observation. This deficient practice had the potential to place Resident 34 at an increased risk of infection from cross-contamination and cause complications associated with oxygen therapy.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain four of four electrical rehabilitation therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This deficient practice had the potential for injury to any resident using the therapy equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when three (3) flies (a type of insect) were observed in the kitchen and food preparation areas during trayline (an area where foods were assembled from the steamtable to resident's plate). This failure had the potential to result in 136 of 140 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within residents' reach while in bed for one of one sampled resident (Resident 91) investigated under the environment task. This deficient practice had the potential to delay the provision of services and resident`s needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to:1. Ensure a copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) was kept in the resident's medical chart and easily retrievable for two of six sampled residents (Resident 8 and 77) reviewed under the advance directive care area. This deficient practice had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care.2. Provide the resident and the resident's representative information regarding formulating an AD for one of six sampled residents investigated during review of the advance directive care area (Resident 5). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) by failing to ensure a resident was able to self-release the ordered self-release seat belt (SRSB)for one of one sampled resident (Residents 93) investigated during review of physical restraints care area This deficient practice had the potential for Resident 93 to result in the restriction of residents' freedom of movement, a decline in physical functioning, and physical harm from entrapment.

Inspectors wroteBased on interview and record review, the facility failed to:1. Provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.2. Provide a written bed-hold notice upon time of transfer to a general acute care facility (GACH, or simply hospital) for one (Resident 37) of four residents investigated for hospitalizations when the resident was not told they would possibly be admitted when they were transferred to a GACH emergency room for a CT scan (CT scan, a medical imaging procedure that uses X-rays and computers to create detailed cross-sectional images of the body). This deficient practice had the potential for the resident to not know the reason for the transfer and to not determine if the reason for transfer was appropriate.

Inspectors wroteBased on interview and record review, the facility failed to submit a new level 1 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) when serious mental illness diagnoses were identified for one of one resident (Resident 11) investigated under PASARR care area. This deficient practice had the potential for Resident 11 not receiving provisions for specialized services.

Inspectors wroteBased on interview and record review, the facility failed to develop a smoking assessment upon a resident`s admission to the facility for one of three sampled residents (Resident 77) reviewed under Accidents care area. This deficient practice had the potential to place Resident 77 at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident`s oxygen tubing had a label including the date and time of when it was last changed for one of one sampled resident (Resident 86) reviewed under Oxygen care area. This deficient practice had the potential to place Resident 86 at an increased risk of infection and cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was incapable of making decisions, was not given a binding arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) to sign for one (Resident 130) of three residents reviewed under the arbitration task. This deficient practice resulted in the resident not knowing or understanding what an arbitration agreement is and potentially causing feelings of doubt, confusion, or distress. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool) was transmitted timely to Centers for Medicare and Medicaid Services (CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to millions of Americans) for two of two sampled residents (Resident 131 and Resident 140) reviewed under Resident Assessment care area. This deficient practice had the potential to result in delayed services for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for two of 60 resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) and/or their Responsible Party (RP- a person assigned to assist or make decisions on behalf of the resident), was provided the opportunity to choose or be informed of their right to choose their attending physician (a medical doctor in charge of the overall care of the resident). This deficient practice resulted in Resident 1 and Resident 1's RP not being made aware of Resident 1's right to select her physician and had the potential to interfere with Resident 1's RP's ability to make an informed choice regarding Resident 1's care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity by failing to assist Resident 1 with obtaining personal belongings from Resident 1's previous facility. This deficient practice had the potential to affect Resident 1's sense of identity, autonomy and emotional comfort.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1's) correct responsible party (RP- a person assigned to assist or make decisions on behalf of the resident) was accurately documented in Resident 1's medical record, and failed to notify the correct RP of Resident 1's room change. This deficient had the potential to result in miscommunication regarding the resident's care and cause confusion for the RP.

Inspectors wroteBased on interview and record review the facility failed to ensure laboratory services were provided timely for one of three sampled residents (Resident 1). This deficient practice may result in a delay in identifying a medical condition and placed Resident 1 at risk of not receiving the necessary care, services and treatment in a timely manner leading to worsening medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to obtain one of four (Resident 1's) weight as ordered by the physician. This deficient practice may result in a delay in identifying significant weight loss or weight gain, and nutritional needs which may lead to a decline in the residents' condition.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory services for one of four sampled residents (Resident 1) by failing to ensure Resident 1 ' s Complete Blood Count (CBC- a blood test that measures the different types and numbers of cells [basic structural and functional unit of all forms of life] in your blood); Comprehensive Metabolic Panel (CMP- a blood test that measures 14 different substances in the blood to assess overall health and metabolism [refers to all the physical and chemical processes in the body that convert or use energy]); Pre-albumin Level (a blood test that measures the amount of pre-albumin [a protein produced by the liver], used to assess a person ' s nutritional status); Serum Iron Test (a blood test that measures how much iron [essential mineral needed by our body for growth and development] is in the blood); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of four sampled residents (Resident 5). This deficient practice had the potential to result in a delay of care and services and possible injury to residents when unable to obtain the needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of medically-related social services to meet one of five sampled residents (Resident 2) needs by failing to follow up the status of Resident 2's missing dentures and ensure timely replacement of Resident 2's denture. On 4/4/2024, Resident 2 was discharged from the facility without providing Resident 2's upper and lower dentures. This deficient practice placed Resident 2 at risk for health and safety impacts such as impair Resident 2's ability to eat leading to weight loss, choke (a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively) or aspirate (when something you swallow goes down the wrong way and enters your airway or lungs) food and may affect Resident 2's speech and social interaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents ' right to be free from abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of four sampled residents (Residents 1 and 2) when on 4/12/2025, Residents 1 and 2, while in their wheelchairs in a hallway, Resident 2 grabbed Resident 1 ' s right arm while Resident 1 grabbed Resident 2 ' s arm. The residents (Residents 1 and 2) then pushed against each other ' s hands and arms, and each resident (Residents 1 and 2) received abrasions (when the surface layers of the skin have been broken). This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility. Resident 1 sustained two abrasions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 1 and 2) received treatment and care in accordance with professional standards of practice by failing to measure Resident 1 and Resident 2 ' s wounds during the assessment of new wounds. This deficient practice had the potential to result in improper wound care and a delay in wound healing to Residents 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident who was at high risk for falls with floor mats (cushioned floor pads designed to help prevent injury should a person fall) as indicated in the care plan for one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at an increased risk of sustaining an injury from a fall.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a dietary communication slip including food allergy information (refers to details about the resident's food allergies [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances]) for one of five sampled residents (Resident 2) upon re-admission to the facility on 3/25/2025 and prior to meal service. This deficient practice had the potential to place the resident at increased risk of being served with food containing food allergens (a substance that causes an allergic reaction) and had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure a resident ' s bed controller was cleaned and disinfected to prevent the spread of germs and infections for one of five sampled residents (Resident 3). This deficient practice had the potential to result in the spread of germs placing residents, staff, and visitors at risk to be infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable environment by failing to: 1. Ensure that the facility staff did not leave an unlabeled drinking cup that contained soap in a resident ' s room for one out of six sampled residents (Resident 1). 2. Ensure a drinking cup unlabeled that contained hair and body shampoo (H&BS) was not left in a utility room (UR - a dedicated area for tasks that involve cleaning, disinfecting, and storing items used in resident care, such as bedpans, urinals, and soap/shampoo/mouthwash). These deficient practices had the potential to place residents, staff, and visitors at risk for unsafe and/or uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's notice of proposed transfer and discharge was provided to the resident at least 30 days prior to discharge or as soon as practicable for two of three sampled residents (Resident 2 and Resident 3). This deficient practice placed Resident 2 and Resident 3 at increased risk of an inappropriate discharge and had the potential to deny the resident of their right to file an appeal to the appropriate agency.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy on urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) care for one of three sampled residents (Resident 1), by failing to provide documented evidence that urinary catheter care was provided to Resident 1 and failing to provide documented evidence of staff monitoring Resident 1's urinary output. This deficient practice had the potential for Resident 1 not to attain their highest functional level.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's attending physician documented a resident's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) within 72 hours following admission for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential for inconsistent care coordination due to incomplete medical records for Resident 2 and Resident 3.

Inspectors wroteBased on interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) had accurate nursing assessments completed daily and accurately documented regarding Resident 1's activities of daily living (ADLs-routine/tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This deficient practice had the potential to negativity affect the resident's quality of life, quality of care, and the quality of services provided.

Inspectors wroteBased on interview and record review the facility failed to ensure physician orders were written accurately for one of three sampled residents (Resident 1) by failing to clarify with the physician Resident 1's potassium chloride (medication used in the management and treatment of low potassium) order for Resident 1 who was unable to self-administer medications. This deficient practice placed Resident 1 at risk for receiving an incorrect dosage of potassium, potentially leading to health complications.

Inspectors wroteBased on interview and record review, the facility failed to clarify with the physician a resident's gastrostomy tube (G-tube-a tube that is places directly into the stomach through an abdominal wall for administration of food, fluids, and medications) feeding order for one of three samples residents (Resident 1). Resident 1's G-tube feeding order did not indicate how many cubic centimeters (CC-unit of measure in volume) and calories (a measurement of the energy content of food) were provided to Resident 1 each day. This deficient practice had the potential to result in Resident 1 having unplanned weight loss or gain and altered nutritional status that can lead to health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who has a diagnosis of cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking (gait), muscle tone, and coordination) received specialized rehabilitative services (special health care services that help a person regain physical, mental, and/or cognitive [thinking and learning] abilities that have been lost or impaired as a result of disease, injury, or treatment). This deficient practice had the potential for Resident 1's to have a decrease in functional mobility, quality of life and higher risk for further decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility ' s Falling Star Program (a program that assesses a resident ' s risk for falling and identifies this at risk) by failing to place an identifying colorful star in the resident ' s personal areas (name plate on entrance to room) for a resident identified at risk for falls for one of three sampled residents (Resident 1). This failure had the potential for staff to be unaware that the resident is at risk for falls, which could increase the resident ' s risk for further falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a safe and comfortable environment when on 11/8/2024, Resident 1 used an electric portable space heater (a device used to heat small rooms or partially enclosed areas) inside the resident's room. This deficient practice placed the residents, staff, and visitors at risk for injury associated with the use of an electric portable space heater including burns and fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident ' s reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and the resident ' s needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility ' s policy on personal alarms by failing to check the functionality of a resident ' s bed pad alarm (a device that will sound if a resident moves) daily for one of three sampled residents (Resident 3). This deficient practice had the potential to place Resident 3 at risk for injuries and falls.

Inspectors wrotec. A review of Resident 489's admission Record indicated the facility originally admitted the resident on 9/13/2021 with diagnoses including but not limited to unspecified dementia, Alzheimer's Disease, psychosis, and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 489's MDS dated [DATE], indicated Resident 489 had severely impaired decision-making skills, physical behavioral symptoms directed towards others (behaviors that affect another person), experienced wandering, and required moderate assistance to complete dressing, toileting, and personal hygiene. During an interview on 8/6/2024 at 9:43 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 489 had a history of wandering around the facility and into other residents' rooms as well as becoming agitated when staff tried to care for her. [...]

Inspectors wroteBased on observation, interview, and record review, the kitchen staff failed to ensure the proper storage, preparation, and distribution of food in accordance with professional standards for food service safety for 139 of 140 residents who receive food from the kitchen by: 1. Failing to ensure five open bags of bread and bagels had a documented open date (when a kitchen first opens the container and writes the date it is open to ensure it is removed from circulation in a timely manner). 2. Failing to ensure the ice machine lid (Cover) was not left open and exposed to the environment. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices by: 1. Failing to ensure that Licensed Vocational Nurse 3 (LVN 3) wore gloves during the medication administration for one of two sampled resident (Resident 14) on enhance barrier precaution (EBP-a method of using personal protective equipment [PPE - equipment designed to protect the wearer from injury or the spread of illness or infection] to reduce the spread of pathogens [germs] between residents). 2. Failing to ensure that facility staff (Activities Assistant [AA]) did not eat personal food inside the resident's dining area alongside resident's eating lunch on 8/6/2024. These deficient practices had the potential to increase the risk of spreading infection amongst resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff (Licensed Vocational Nurse 1 [LVN 1]) knocked on a resident's door before entering the resident's room for one of 31 sampled residents. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure that an Advance Directives (AD-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) were discussed and written information were provided to the residents and or responsible parties for two of 10 sampled residents (Resident 34 and 81) 2. Obtain a copy of the Advance Directive for one of seven sampled residents (Resident 81) and place the Advance Directive in the chart to be available and retrievable at any time per facility policy. These deficient practices have the potential to create confusion which could lead to conflict with the resident`s wishes regarding his/her health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that facility staff (Licensed Vocational Nurse 1 [LVN 1]) provided privacy to one of 31 sampled residents (Resident 118) during the administration of medication via gastrostomy tube (g-tube - a small, soft tube that is surgically inserted through the abdomen and into the stomach). This deficient practice violated Resident 118's right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 440) was free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or next to the resident's body that he or she cannot easily remove and restricts freedom of movement or normal access to one's body) of a non-self-release seatbelt (NSRB - when the user of the restrain is unable to release it themselves). This deficient practice placed Resident 440 at increased risk for complications of restraint use such as decline in functioning, injury, and entrapment (event in which a resident is caught, trapped, or entangled in a space where they are being restrained).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) did not sign the Medication Administration Record (MAR - a report detailing the medications administered to a resident by a healthcare professional) for one (Resident 118) out of 31 sampled residents before the administration of Dorzolamide hydrochloride-Timolol maleate (medication eye drop used to treat increased pressure in the eye caused by open-angle glaucoma or a condition called hypertension of the eye) and Prednisolone acetate (medication eye drop used to treat certain eye conditions due to inflammation or injury). This deficient practice had the potential to result in the resident's medical records being inaccurate and not in accordance with professional standards of practice.

Inspectors wroteBased on interview, and record review the facility failed to ensure that Licensed Vocational Nurse 2 (LVN 2) documented the presence of a hematoma (also known as a bruise, it is a discolored mark on your skin that forms when blood vessels under your skin break) to the left dorsal hand (back of the hand) of one of three sampled residents (Resident 61) as ordered by the physician. This deficient practice had the potential for Resident 61 to not to receive the care and services needed to treat Resident 61's discoloration.

Inspectors wroteBased on interview and record review, the facility failed to ensure that facility staff provided one of one sampled resident (Resident 47) with a scheduled toileting plan (or bladder training, which can involve assisting a resident to the restroom at specific timed intervals) This deficient practice has the potential for Resident 47 to not to achieve or restore normal bowel (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder (A sac-shaped muscular organ that stores the urine secreted by the kidneys) function.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the recommendation of the Consultant Pharmacist`s (CP) to monitor the respiratory rate (RR-the number of breaths a resident takes per minute) and adding a parameter to hold (do not give a medication) the medication of Oxycodone Hydrochloride (Oxycodone HCL -medication to treat pain) if the RR of a resident is less than 12 breaths per minute ( normal respiratory rate is 12-20 breaths per minute) for one of five sampled residents (Resident 47) was done during the Medication Regimen Review (MRR-A review of the medication regimen of a resident to identify and, if possible, prevent clinically significant medication issues) for 5/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurse 1 (LVN 1) locked one of three medication carts (Medication Cart 1) before leaving it unattended during a med pass observation. This deficient practice had the potential to result in unauthorized personnel or residents accessing the medications stored in the unlocked medication cart.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 108) received an accurate assessment, reflective of the resident's status by not including the following diagnoses in the resident's Minimum Data Set (MDS - an assessment and care screening tool): 1. Congestive Heart Failure (CHF - a condition when the heart cannot pump enough blood to meet the body's needs, causing fluid to build up in other parts of the body). 2. Atrial Fibrillation (AFIB - an irregular heartbeat when the upper part of the heart sends electrical signals rapidly and at the same time). 3. Pulmonary Hypertension (PMH - a chronic condition when the blood pressure in the lungs is higher than normal). 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for two of 60 resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve the grievance of one of seven sampled residents (Resident 2). This deficient practice violated the residents' right to have their grievance addressed.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an injury of unknown origin (injuries resulting without knowing how it happened) that occurred on 7/6/2024 for one of two sampled residents (Resident 3). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a standardized assessment and care planning tool) Assessment Section GG (Functional Abilities and Goals) on 5/3/2024 by failing to indicate the resident's use of a motorized wheelchair (known as powerchair or electric wheelchair, a wheelchair that is propelled by means of an electric motor rather than manual power) for one of two sampled residents (Resident 2). This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of services.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for two of seven sampled residents (Resident 1 and 2) to address the use of motorized wheelchair (known as powerchair or electric wheelchair, a wheelchair that is propelled by means of an electric motor rather than manual power) while alone and on out on pass (OOP - away from the facility). These deficient practices had the potential to result in lack of delivery of care and services and placed residents at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure History and Physical (H&P- contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status) Examinations for two of seven sampled residents (Resident 3 and Resident 4) were completed by the physician. This deficient practice had the potential for inconsistent care coordination due to incomplete H&P and placed Resident 3 and Resident 4 at risk for poor continuity of care and care needs.

Inspectors wroteBased on interview and record review the facility failed to notify the responsible party of a change in condition (COC- when there is a sudden change in a resident's health) for one of three sampled residents (Resident 1) when Resident 1 had a significant nine (9) pounds (lbs. - unit of measure) weight loss in a week (from 12/19/2020 to 12/26/2020). This deficient practice has the potential outcome to have had a negative effect on Resident 1's nutritional status if any decisions were needed at the time of the change of condition.

Inspectors wroteBased on interview and record review, the facility failed to determine resident specific interventions for a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) related to falls for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay in or lack of delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician order for monitoring intake (amount of fluid a person consumes) and output (the amount of fluid a person excretes from the body) was done for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to experience a in delay in necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three sampled residents (Resident 1) was provided with the necessary behavioral health care and services by not obtaining a psychological (pertaining to mental or emotional) evaluation for Resident 1 as ordered by the physician. This deficient practice had the potential to negatively impact Resident 1 ' s mental health including increasing the risk for depression, anxiety, directly affecting the resident ' s psychosocial wellbeing.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three sampled residents (Resident 1) was provided with social service assessments and needs as indicated in the facility ' s policy and procedures during the duration of Resident 1 ' s stay in the facility. This deficient practice had the potential for Resident 1 not to maintain the highest practicable physical, mental, and psychosocial well-being; and increased the risk of a delay in delivery of care and services needed for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to inform and obtain written authorization from the resident prior to completing two government agency forms titled Request To be Selected as Payee (a person authorized by the government to act on behalf of the resident to manage financial matters) (a government form used to process a potential representative payee's application) and Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits (a government form used to collect information to make a determination regarding the resident's need for a representative payee) to manage the resident's personal funds for one of three sampled residents (Resident 3). This deficient practice resulted in the violation of Resident 3's rights and had the potential for misuse of Resident 3's personal funds.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of verbal abuse within two (2) hours of the incident for one of five sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one of six facility staff (Rehab Staff 1 [RS 1]) performed hand hygiene (washing of hands) before wearing gloves and after providing direct care. 2. Failing to ensure one of six facility staff (Certified Nursing Assistant 1 [CNA 1]) performed hand hygiene before entering and exiting an enhanced standard precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO - bacteria that have become resistant to certain antibiotics {medication used to fight infections}] in nursing homes) room. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR- a federal requirement to help ensure individuals with mental disorders or intellectual disabilities are not inappropriately placed for in nursing homes for long term care) was accurately completed for one of four sampled residents (Resident 1). Resident 1's PASARR Level I Screening Document was inaccurately completed upon admission on [DATE]. This deficient practice resulted to Resident 1 not being referred to the PASARR Program and placed the resident at risk for not receiving care and services in an appropriate healthcare setting.

Inspectors wroteBased on interviews and record reviews the facility failed to protect the right of one of four sampled residents (Resident 1) to have their legal and medical decision maker, Family Member 1 (FM 1), be informed about Resident 1's care and to choose what care Resident 1 received while in the facility by: 1. Failing to obtain an informed consent (approval) for the administration of the antipsychotic medication (a potentially dangerous type of medication that effects mood, behavior, thoughts, and perceptions that are associated with increased risk of death) known as Seroquel from Resident 1's responsible party. 2. Failing to ensure Resident 1's responsible party participated in the resident's Interdisciplinary Team (IDT- an approach to healthcare that integrates multiple disciplines through collaboration) care plan meetings. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain complete and accurate medical records for one of four sampled residents (Resident 1) by: 1. Failing to ensure facility staff did not document that Resident 1's responsible party (Emergency Contact 1 [EC 1]) was contacted and provided informed consent (approval) for the administration of the antipsychotic medication (a potentially dangerous type of medication that effects mood, behavior, thoughts, and perceptions that are associated with increased risk of death) known as Seroquel. 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to review the risks and benefits of side rail usage; and obtain informed consent (approval) prior to installation from the responsible party (Emergency Contact 1 [EC 1] and Emergency Contact 2 [EC 2]) for one of four sampled residents (Resident 1). These deficient practices resulted in Family Member 1 (FM 1) not having the chance to give informed consent for the facility's use of side rails on Resident 1's bed which could have resulted in Resident 1 suffering injury related to entrapment (to be trapped) in the side rails.

Inspectors wroteBased on interview and record review the facility failed maintain the right to privacy for one (1) of three (3) sampled residents (Resident 1) by taking an unauthorized photograph of Resident 1 while providing daily care. This deficient practice violated the right to privacy for Resident 1 and had the potential to have feelings of embarrassment and negativity impact Resident 1 ' s socialization.

Inspectors wroteBased on interview and record review the facility failed to obtain paperwork and follow up information regarding a medical appointment for one of five sampled residents (Resident 1). Resident 1, who requires a hematologist (a doctor who specializes in diagnosing, treating, and preventing blood disorders) appointment that was scheduled for 11/21/2023, was not provided timely. This deficient practice resulted in a delay of necessary treatment, caused Resident 1 ' s appointment to be rescheduled to 12/29/2023 and could result in a decline in medical condition.

Inspectors wroteBased on interview and record review, the facility failed to arrange transportation services to a resident ' s appointment with a hematologist (a doctor who specializes in diagnosing, treating, and preventing blood disorders) for one of five sampled residents (Resident 1). This deficient practice had the potential to result in negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to include a copy of the advance directives (written statement of a person's wishes regarding medical tratement made to ensure those wishes were carried out should the person be unable to communicate to a doctor) and to provided a discussion to the residents and/or responsible parties for seven out of seven sampled residents (Resident 14, 31, 47, 52, 43, 54 and 103). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding alternatives in the provision of health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five sampled residents' (Resident 18, 43, 52, 108, and 115) environment remained free from accident hazards by: 1. Failing to ensure Resident 18 and Resident 43's environment was free of clutter and accidental hazards. This deficient practice has the potential to place Resident 18 and Resident 43 at an increased risk for falls. 2. Failing to ensure the side rails were padded per physician's order for Resident 52 who had a history of seizures (sudden, uncontrolled electrical activity in the brain). This deficient practice had the potential for Resident 52 to suffer an injury during a seizure episode. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for one of nine sampled residents (Resident 87) investigated during the facility task Medication Storage and Labeling. 2. Ensure Licensed Vocational Nurse 6 (LVN 6) documented the dispensing and administration of lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) on the CDR and on the MAR for one of nine sampled residents (Resident 1) investigated during the facility task Medication Storage and Labeling. 3. Ensure Licensed Vocational Nurse 8 (LVN 8) documented accurately in a resident's record regarding medications being administered for Resident 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policy and procedures for five of five sampled residents (Resident 120, 18, 43, 104, and 27) by failing to: 1. Ensure Social Services Assistant (SSA) wore an N95 (filtering mask) before entering and speaking to Resident 120, who was in contact/droplet isolation precautions in the yellow zone (cohort of the facility consisting of mixed quarantine and symptomatic coronavirus disease-2019 (COVID-19 a highly contagious viral infection that can trigger respiratory tract infection). 2. Ensure Resident 120's Caregiver 1 (CG 1) removed the soiled gown and gloves before exiting the resident's room. 3. Ensure Screening for COVID-19 Form for Visitors and Employees were completed prior to entry to the facility. 4. Ensure Resident 18's and Resident 43's personal items were not on the floor. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident at eye-level for one of one sampled resident (Resident 103) during assistance with meals. This deficient practice had the potential to affect the resident's self-worth.

Inspectors wroteBased on interview and record review, the facility failed to identify and investigate a grievance concern of a missing tooth for one of one sampled resident (Resident 109). This deficient practice has the potential to delay in addressing Resident 109's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse policy, for one (Resident 86) of one sampled residents, as evidenced by: 1. Ensuring Certified Nursing Assistant 1 (CNA 1) was suspended immediately following an abuse allegation. 2. Ensuring the allegation was investigated immediately the same day of the abuse allegation when the abuse allegation was first known by staff. These deficient practices had the potential for Resident 86 to feel isolated and unsafe in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sexual abuse allegation by facility staff was reported to the appropriate state agency within two hours for one of one sampled resident (Resident 86) on 1/09/2022. This deficient practice resulted in Resident 86 to feel unprotected and unsafe when the investigation was not acted upon in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 28 sampled residents (Resident 26) care plan was reviewed and revised to reflect the current status and interventions being provided to the resident. This deficient practice placed the resident at risk of unrecognized change of condition and a delay of necessary intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist Resident 270 to clean his fingernails during his morning care. This deficient practice has the potential to result in a skin infection and that may affect Resident 270's self-esteem without being clean.

Inspectors wroteBased on observation, interview, and record review, the facility to provide the needed care and services, for two of two sampled residents, as evidenced by: 1. Failure to ensure psychological support was provided by Resident 86 following alleged abuse. 2. Failure to accurately monitor for complications related to anticoagulant (medication used to help prevent blood clots) use for one of one sampled resident (Resident 47). These deficient practices had the potential to result in a delay or lack of delivery of care and services for Resident 47 and 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the tubing for the urinary catheter (device that is inserted into the bladder to collect and drain urine) was secured with an anchor as ordered by the physician for one of two sampled residents (Resident 31). This deficient practice had the potential for the urinary catheter to accidentally get pulled on and become dislodged, resulting in injury.

Inspectors wroteBased on interview and record review, the facility failed to provide effective pain management for two of two sampled residents (Resident 109 and Resident 36) by failing to administer the residents' pain medications as ordered by the physician when Resident 109 and Resident 36 reported a pain scale level 7 or greater considered as severe pain according to the facility's pain management policy. This deficient practice had the potential to result in ineffective pain management and poor compliance to treatment and may result in poor recovery outcomes for the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow-up and ensure the physician provided a rationale (underlying reason) for disagreeing with the pharmacy consultant's recommendation for gradual dose reduction (GDR - stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of psychotropic (drug that affects behavior, mood, thoughts, or perception) medications for one of five sampled residents (Resident 52) investigated under the care area of Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review. This deficient practice had the potential for Resident 52 to continue to receive unnecessary medications, placing the resident at risk for possible adverse consequences (any unexpected or dangerous reaction to a drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 132 of 136 residents who are served food from the kitchen by: 1. Failing to ensure one dietary staff wore a hairnet while in the kitchen. 2. Failing to discard an open gallon of skim milk by its use-by-date (last date recommended for the use of the product). These deficient practices had the potential to result in cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface or substance to another) of food and equipment and can lead to foodborne illness (any illness resulting from the spoilage of contaminated food, pathogenic bacteria/germs, viruses, or parasites that contaminate food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for one of one sampled resident (Resident 97) by failing to address an issue with a faulty door stop which allowed the bathroom door to hit the sliding glass door to the outdoor patio when it is opened. This deficient practice had the potential for the glass to break when the bathroom door is opened, resulting in possible injury of residents and staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for 2 of 60 resident rooms (rooms [ROOM NUMBERS]). This deficient practice had the potential to result in inadequate space to provide sufficient nursing care and privacy for the residents.