West Hollywood Healthcare & Wellness Centre, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was permitted to remain in the facility pending the results of an appeal of a discharge. Resident 1 submitted an appeal for the discharge on [DATE]; however, the facility discharged Resident 1 on the same day, prior to receiving the appeal decision. On 5/23/26, Resident 1's appeal to remain in the facility was approved, but Resident 1 had already been transferred from the facility. This deficient practice resulted in Resident 1 being discharged without due process, which could negatively impact Resident 1's continuity of care and treatment. During a review of Resident 1's Face Sheet (FS) dated 6/2/2026, the FS indicated Resident 1 originally admitted on [DATE] and re-admitted on [DATE], with the diagnoses that included but not limit to: [...]

Inspectors wroteBased on interview and record review, the facility failed for one of three sampled residents (Resident 1) to:1. Develop a policy and procedure for acceptance of gifts, money, or items of value from residents by facility staff.2. Implement its' policy titled Resident Funds by failing to ensure staff (Medical Records Director) did not handle resident's money/check.3. Establish clear expectations, staff guidance, requirements of financial transactions, and reporting requirements related to resident gifts to staff to ensure protection of resident funds in accordance with resident rights and abuse prevention requirements. These deficient practices had the potential to place residents at risk for financial exploitation and abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident funds were safeguarded from misappropriation (unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of personal funds when facility staff deposited a resident's personal check into the staff member's personal account for of three sample residents, Resident 1. This deficient practice had the potential for financial exploitation, loss of resident funds, and psychosocial harm to Resident 1.

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 by failing to ensure: 1. Food is labelled with expiration date 2. Discard expired foods 3. Food refrigerator(s) and freezers were clean. 4. Implement food cooling down method according to the facility policy and procedures titled Hazardous Foods Cooling Monitor dated 1/27/2025. 5. The Ice machine and the water fountain are not dirty These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses and other toxins) medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control measures by failing to ensure the end of a gastric tube (GT- is a tube inserted through the abdomen into the stomach for nutrition, hydration, and medication) that is connected to a resident was secured, capped, and was not on the floor for one of two sampled residents (Resident 4). This deficient practices had the potential to result in infection and hospitalization for Resident 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain one of two laundry service rooms (laundry room [ROOM NUMBER]) in good repair. By failing to ensure the floors were free of cracks, buckets holding chemicals were free of cracks and holes, the ceiling was clean, and the door leading to the trash area was intact. These deficient practices had the potential to result in an infestation of rodents, and or pests such as ants and roaches due to holes and substantial cracks found in the floor, and open pipes, including a broken door leading to the trash area of the laundry room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 13 out of 34 rooms (room [ROOM NUMBER], 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33) met the 80 square feet (sq. ft.) per resident This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 39 Residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure closet doors were functional in nine of nine resident rooms (Rooms 17, 18, 20, 21, 22, 23, 24, 25, and 26). This failures had the potential to cause harm to the residents.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 6), the facility failed to notify a physician of an abnormal potassium level (electrolyte in the body that regulates heart muscle contractions and maintaining proper electrical signals within the heart) level of 5.6 (milliquivalent per liter (mEq/L - unit of measurement. Reference range 3.5 to 5.1 mEq/L) on 6/6/2025 at 11:26 P.M. Resident 6's physician was not notified of the abnormal potassium level until 6/7/2025, at 5:50 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow the doctors orders by covering sacral wound for Resident 32. 2. Ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's need by puttying a dressing on the resident's sacral pressure (refers to the pressure exerted on the sacrum [the bony area at the base of the spine) due to prolonged sitting or lying down]) injury. These failures had the potential to cause further injury and infection to the Resident 32's sacral pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to provide intravenous catheter (IV -a thin, flexible tube inserted into the vein to deliver fluids, medications, or other treatments directly into the blood stream) treatment in accordance with professional standards for one of one sampled resident (Resident 6) by failing to remove Resident 6's IV catheter on 6/8/2025 when ordered IV hydration was completed. This deficient practice had the potential to result in infection and possible hospitalization for Resident 6.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of one sampled resident (Resident 19), by failing to: 1. Ensure Resident 19's oxygen tubing was changed weekly in accordance with the facility's policy and procedures (P&P) titled Oxygen Therapy revised 1/27/2025. 2. Ensure a physician's order for oxygen was complete and accurate in accordance with the facility's P&P titled Physician Orders revised 1/27/2025. This deficient practice had the potential to result in infection, medication error and possibly hospitalization for Resident 19.

Inspectors wroteBased on record review and interview the facility failed to ensure one of three sampled residents (Resident 59) who required dialysis (a medical treatment that cleans the blood when the kidneys are unable to do so) received services consistent with professional standards. By failing to assess the resident's current vital signs (body temperature, blood pressure, pulse [heart rate], and breathing rate to help assess the general physical health of a person) prior to transporting the resident to the dialysis center. This deficient practice had the potential for Resident 59 to experience adverse complications that would not be identified by facility staff in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed, offered or followed up regarding Advance Directive (ACHD - 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) in a timely manner for four of 18 sampled residents (Residents 48, 43, 3, and 58). This deficient practice had the potential to cause conflict with resident's wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when the resident continued to refuse to take her medications for one of two sampled residents (Resident 58). This deficient practice had the potential to result in delayed provision of necessary care, treatment and services.

Inspectors wrote1d. A review of Resident 44's admission Record indicated Resident 44 was originally admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses including injury of head, dementia (loss of cognitive functioning-thinking, remembering, and reasoning), generalized weakness, history of falling and epilepsy (a disorder in which a nerve cell activity in the brain is disturbed causing seizure [a sudden, uncontrolled electrical disturbance in the brain]). A review of Resident 44's MDS dated [DATE], indicated Resident 44's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was moderately impaired and requiring maximal assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement individualized (resident-specific) comprehensive care plans (plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for 12 out of 12 sampled residents (Residents 36, 40, 227, 277, 278, 48, 43, 50, 3, 178, 330 and 44) by: 1. Failing to develop and implement care plans for bilateral upper bed side rails as mobility enabler (assist in turning and transferring in and out of bed) for residents 36, 40, 277, and 278. 2. Failing to develop and implement a care plan for Resident 277's Venofer (iron sucrose - an IV iron medication) intravenous (IV, medical technique that administers fluids, medications, and nutrients directly into a person's vein) solution 100 milligrams (mg) intravenously in the evening for iron deficiency. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practical emotional/physical well-being and pain management for two of two sampled residents (Resident 9 and Resident 58), by: 1. Failing to administer Resident 9's Lidocaine External Patch 5 percent (% - unit of measurement)- apply to affected area topically one time a day for pain management leave on for only 12 hours only within a 24-hour period at the scheduled time (9:00 a.m.). 2. Failing to remove Resident 9's lidocaine patch (a prescription-only topical local anesthetic) 12 hours after application as per physician's order and timely administered medications per physician's order. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient staffing to accommodate resident needs by not answering call lights (device(s) with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) in a timely manner for four of five sampled residents (Resident 8, 18, 50 and 53). This deficient practice resulted in Resident 8, 18, 50 and 53 not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to all 72 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff possessed the appropriate competencies to provide nursing and related services to assure resident safety four of nine sampled nursing staff (Registered Nurse 1-RN 1, Infection Prevention Nurse 1-IPN 1, Certified Nursing Assistant 4-CNA 4 and Certified Nursing Assistant 7-CNA 7) had the specific competencies and skills sets necessary to care for the residents. This deficient practice had the potential to lead to inadequate care and a delay resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services included procedures to ensure the emergency kit (e-kit - secured container or secured electronic system containing drugs which are used for either immediate administration to residents or in an emergency or as a starter dose) was securely sealed and medciation used from the E-kit was reordered. By failing to: 1. Ensure the Intravenous (IV, insertion of a cannula or catheter into a vein to provide access to the bloodstream) E-kit located in one of one sampled medication storage closet (medication storage closet 1) was properly resealed, had an open date documented, and medication used was reordered. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents in the facility by failing to: 1. Ensure proper disposal of an open sterile central line (a small, soft tube called a catheter is put in a vein that leads to your heart, used for delivering fluids or medications for a longer period of time) dressing kit, and expired sterile (completely clean and free from germs) needles, alcohol pads (small gauze pads saturated with alcohol used as an disinfectant), and saliva collection kit (syringe used to collect saliva for a lab test). 2. Ensure opened medication bottles/containers for acidophilus (prebiotic medication) and bismuth subsalicylate (medication that relieves symptoms of upset stomach) were dated when opened. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu and provide resident a variety of food options when: 1. One resident (Resident 48) who was on a renal diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease or who are on dialysis) received chicken jambalaya (mixed rice, chicken, and tomato dish) instead of Baked chicken and rice per menu. 2. Residents who were on vegetarian and vegan diets (Resident 69, Resident 61 and Resident 9) complained that the menu does not have variety of vegetarian options and Resident 61 complained that last week fish sticks were served every day for lunch. This deficient practice had the potential to result in inadequate nutrition status and meal dissatisfaction when the menu is not updated to reflect the needs of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents were served the food with preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) and received substitute meal options of similar nutritive value when: 1. One resident (Resident 69) food preferences were not honored by serving fish sticks during lunch, despite Resident 69's diet order indicated Vegan. 2. Two residents (Resident 61 and Resident 9) who are vegetarians and do not eat meat, received 3 fish sticks for alternate protein choice that had lower protein content than the beef paprika (diced beef and spices) and the roasted pork chop that was on the regular menu. This deficient practice had the potential to result in decreased meal satisfaction, decreased nutritive value for the meal, which could lead weight loss and other health issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation when: Food brought to resident from outside of the facility, including leftovers stored in the resident food refrigerator were not dated. There was no monitoring system for the refrigerator temperatures and expired food was not discarded. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 67 out of 70 residents who received food from facility including the residents who had their food stored in the resident refrigerator.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility's Administrator (ADM) who was responsible for providing effective leadership, oversight, safe access to residents, staff, and visitors, policies, and procedures throughout the recertification process-maintained professionalism and appropriate behavior. This deficient practice impeded the completion of an investigation, placing facility residents at risk for the spread of infections, delays in care, and had the potential to make residents, visitors, and staff feel threatened.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to implement their infection control policy and procedures (P&P) for five of 19 by failing to: 1. [NAME] (put on) appropriate personal protective equipment (PPE) when disconnecting Resident 3 from the gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) and while assisting Resident 3. 2. [NAME] appropriate PPE when Certified Nursing Assistant 4 (CNA 4) was assisting Resident 178 during basic care. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement facility's protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/resident) for three of three sampled residents (Resident 13, 178, and 278). This deficient practice had the potential for Resident 13, 178, and 278, to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use, which could lead to adverse events including allergic reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's right to be informed were honored and implemented accordingly to her decision on health care treatment for one of five sampled residents (Resident 43). This deficient practice violated resident's right to make an informed decision and resulted to failure in the delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to enhance a resident's dignity and respect by failing to provide personal hygiene and assistance to one of five sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure residents' rooms were kept with comfortable sound levels maintained for two of five sampled residents (Residents 18 and 53). This deficient practice had the potential to negatively impact the resident's quality of life and placing Residents 18 and 53 an increased level of discomfort and inability to sleep during the night.

Inspectors wroteBased on observations, interview, and record review the facility failed to identify and notify the Medical Director (MD) about a change in condition for Resident 62's noncompliance of not using a humidifier (are devices that add moisture to the air to prevent dryness that can cause irritation in many parts of the body) for his oxygen. This deficient practice had the potential to place Resident 62 at a risk of having dry mucus membranes mucus membranes which could lead to break in skin resulting in bacteria entering through the broken skin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from risks and hazards for one of six sampled residents, (Resident 48) by failing to ensure Resident 48's Desitin cream (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations [such as diaper rash, skin burns from radiation therapy]) inside the resident's bedside drawer and [NAME] tears eyedrops (used to help relieve dryness of the eyes) were not left on top of the resident's bedside table by facility staff without a proper physician's order and per facility's policy and procedures (P&P) titled Self-Administration of Medications with a review date of 1/29/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide intravenous (IV, insertion of a cannula or catheter into a vein to provide access to the bloodstream) access care consistent with professional standards of practice and as per facility policy and procedures (P&P) titled Central Venous Catheter Dressing Changes dated May 2022, for two of two sampled residents (Residents 277 and Resident 278). By failing to ensure: 1. A care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) was developed and implemented for Resident 277's IV therapy. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of two sampled residents (Resident 3 and Resident 10) by failing to ensure: 1. Resident 3 received oxygen at 2 liters per minute (l/min - unit of measurement) via nasal cannula (NC - a device used to deliver supplemental oxygen that should be placed directly on the resident's nostrils) to keep oxygen saturation (O2 sat) above 93 percent (% - unit of measurement) every shift for shortness of breath (SOB)/desaturation (the condition of a low blood oxygen concentration) as per physician's order dated 1/17/2024. 2. Resident 10 received oxygen at 2l/min via NC to keep O2 sat above 93 percent every shift for SOB every shift, as per physician's orders dated 8/18/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 46) received the care and services consisted with professional standards of practice for hemodialysis (HD-filtering the blood of a person whose kidneys are not working normally) by failing to assess and documented resident 46's condition for complications after hemodialysis treatment. This deficient practice had the potential to allow for unidentified malfunctioning AV shunt, infections and bleeding from the AV shunt site which could all lead to serious harm and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the facility staff in an area accessible to the public for one of four days (5/25/2024) for the month of May 2024. As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors. And had the potential to cause inadequate staffing.

Inspectors wroteBased on interview and record review, the facility failed to communicate the consultant pharmacist's recommendation, in the Medication Regimen Review (MRR), to the attending physician for two of five sampled residents (Resident 15 and 53). This deficient practice had the potential for unnecessary medication use, resulting in an adverse drug reaction to affect the health and wellbeing of Resident 15 and Resident 53.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fortified diet (diet enhanced to increase caloric content) as ordered by the physician to one of 21 sampled residents (Resident 36) who was on a kosher (food that complies with a strict set of dietary rules in the Jewish religion) and fortified diet. This deficient practice had the potential to result in decreased caloric intake and lead to undesirable weight loss for the resident.

Inspectors wroteBased on observation and interview, the facility failed to maintain patient care equipment in safe working condition when one of six sampled residents (Resident 3) had an uncovered overhead light with exposed bulb. This deficient practice had a potential to cause incidental accidents to the resident, which could result in injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 13 out of 34 rooms (room [ROOM NUMBER], 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33) met the 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of three of 16 sampled residents (Resident 26, Resident 28, and Resident 48) by failing to: -Develop a plan of care for Resident 26 who was using oxygen for shortness of breath. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for the use of four doses of controlled substances (medications with a high potential for abuse) for four residents (Residents 23, 27, 57, and 213) in two of two inspected medication carts (Medication Carts 2A and 2B). This deficient practice increased the risk that Residents 23, 27, 57 and 213 could have received too much or too little medication due to lack of documentation, possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two medications were labeled with an open date per the manufacturer's requirements in one of two inspected medication carts (Medication Cart 2A) affecting Residents 48 and 214, and the facility failed to remove one expired medication from one of two inspected medication carts (Medication Cart 2A) affecting Resident 57. These deficient practices increased the risk that Residents 48, 57, and 214 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, staff interviews, record review, the facility failed to ensure safe and sanitary food storage and food preparation practices when: -Raw chicken stored on top of beef brisket and next to raw fish in the reach in refrigerator. -Ice machine ice dispenser and spout internal compartment was dirty. -Dishwahser staff did not wash hands or change gloves when removing the clean and sanitized dishes form the dish machine. -Food brought to residents from outside of the facility, including leftovers, stored in the resident refrigerator were not labeled. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 66 of 67 residents who received food and ice from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an indwelling catheter (a tube left in the bladder that drains urine) drainage bag was placed in a dignity bag (a concealment device used to block the view of the contents of a urinary catheter bag, a collection bag connected to a tube inserted into the body to collect urine) to provide privacy for one of three sampled residents (Resident 17). This deficient practice had the potential for resulting to psychosocial harm and violating Resident 17's right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the call light (device used to alert the facility staff that a resident requires assistance) within reach in the resident's room for two of 17 sampled residents (Resident 35 and 48). This deficient practice had the potential to result in the delay of provision of services and not allow the resident to call for help when needed or emergencies which could lead to harm to Resident 35 and 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation clarifying if a resident had an advanced directive (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) or not for two of three sampled resident (Residents 5 and 22)

Inspectors wroteBased on interview and record review, the facility failed to ensure Beneficiary Protection and Notification forms were given to one of three sampled residents (Resident 3). This deficient practice had the potential to result in Resident 3 incurring an unknown financial liability to the facility or Resident 3 not being able to exercise his right to an appeal.

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plan for one of five sampled resident (Resident 28) who was receiving furosemide (Laxis - a medication used to treat fluid retention (holding) by increasing the amount of urine voided by the body). This deficient practice had the potential for Resident 28 not to receive the appropriate care treatment and/or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for a resident who had an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage), the indwelling catherter bag was anchored (secure) below the resident's bladder for one of two sampled residents (Resident 6). This deficient practice had the potential to result in recurrence of urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) and had a potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection) or harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to follow through on one recommendation from the consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report irregularities) from February 2022 to consider a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication to the lowest effective dose) on Depakote (a medication used to treat mental illness) in one of five sampled residents (Resident 48.) The deficient practice could have resulted in Resident 48 experiencing preventable complications from her medication therapy, possibly leading to a diminished quality of life.

Inspectors wroteBased on observation interview and record review, the facility failed to provide appropriate monitoring of Heparin (a medication used to prevent blood from clotting in the heart or blood vessels) for one of five sampled residents (Resident 35). This deficient practice had the potential to result in complications from the use of heparin such as bruising and bleeding to Resident 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed for two of 16 sampled residents (Residents 26 and 36) by: -Failing to ensure Resident 26's oxygen nasal cannula tubing (nc - a device used to deliver supplemental oxygen placed directly on a resident's nostrils) and humidification bottle was dated. -Failing to ensure Resident 36's gastric drainage tubing and the attached cannister were off the floor. These deficient practices caused an increased risk in contamination with the potential for infections for Residents 26 and 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 13 of 34 resident rooms met the square footage requirement of 80 square feet (sq. ft) per resident in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.