Westview Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with standards for food safety when fresh produce was not labeled or dated correctly to inform staff when the food was safe to use by. This failure had the potential for all residents in the facility who eat food from the kitchen to contract food-borne illness related to consuming food past their use by date. During an observation on 5/5/26, at 8:10 a.m., in the facility walk-in refrigerator, a plastic container of onions were observed without a label to indicate the received date or a use by date. During an interview on 5/5/26, at 8:10 a.m., with the Dietary Director (DD), DD stated there are no labels on the onions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and keep secure when not in use, confidential resident health records for a census of 154. This failure had the potential to expose and disclose personal and confidential health information to unauthorized individuals. During a medication pass (med pass) observation on 5/5/26 at 8:08 a.m. with Licensed Nurse 15 (LN 15), LN 15 was observed preparing medications for Resident 122. As LN 15 prepared the medications, she placed the empty bubble packs on their side on top of the medication cart (med cart), positioned with the long thin edge on the cart so that the blisters faced sideways and the pharmacy labels faced outwards. The pharmacy labels contained confidential resident information. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five of 37 sampled residents (Resident 7, Resident 140, Resident 8, Resident 11, and Resident 156) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when:Resident 7 received psychotropic medication without behavior monitoring and nursing staff did not implement nonpharmacological (non-drug) interventions;Resident 140's psychotropic medication dosage was increased without documented clinical rationale and nonpharmacological interventions were not implemented;Resident 8's as needed psychotropic medication was extended without documented clinical rationale and nursing staff did not document which nonpharmacological interventions were implemented; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure patient safety for medication use for six of 37 sampled residents (Residents 7, 8, 11, 76, 116 and 153) when: Nursing staff administered the incorrect probiotic to Resident 153;Nursing staff did not educate and assist Resident 76 to ensure he correctly administered his inhaler;Multiple incomplete and unclear PRN (as needed) pain medication orders were not clarified for indication for use (e.g. mild, moderate, or severe pain) prior to administration. Medication orders were not scheduled for administration according to the physician's orders to avoid drug interactions for Resident 7; andNursing staff did not notify the physician in accordance with the order when Resident 11's blood sugar (BS) was greater than 200. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for six residents (Resident 13, Resident 146, Resident 85, Resident 159, Resident 94, and Resident 151), for a census of 154, when:1a. Resident 13's intravenous antibiotic (IV ATB- medications used to treat infections delivered directly into the bloodstream through a vein for immediate action) was initialed as given by a Licensed Vocational Nurse (LVN- healthcare professional providing basic nursing care under the supervision of a Registered Nurse or RN);1b. Resident 146's IV ATB medication was initialed as given by an LVN;1c. Resident 85's IV ATB treatments were initialed as given by LVN; 1d. Resident 159's IV ATB medication was initialed as given by an LVN;1e. Resident 94's IV ATB medication was initialed as given by an LVN; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing assistant (RNA: is a certified nursing assistant (CNA) with specialized training who helps residents in skilled nursing facilities maintain or regain functional independence, mobility, and strength) services to two of 37 sampled residents (Resident 72 and Resident 143) according to professional standards when:Facility staff did not have documented evidence Resident 72 had his arm brace/splint applied daily according to physician orders, 2. It was not documented that Resident 143's hand splint was put on and removed according to the physician order. These failures had the potential for Resident 72 and Resident 143 to have a decline in mobility or range of motion (ROM: the full movement potential of a joint).1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:Nursing staff disposed of medication that was prepared but not administered in accordance with facility policy and procedure (P&P);Emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were replaced timely after use and removal of medications documented for a census of 154;Medications with discontinued orders were securely stored in a designated area until time of destruction;Ensure the availability of routine medications for one of 37 sampled residents (Residents 134). [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 14.29% error rate when five medication errors out of 35 opportunities were observed during a medication pass for three of six Residents (Residents 76, 134, and 158). This failure resulted in medications not given in accordance with the prescriber's order and the potential to affect residents' clinical conditions, and unwanted exposure to hazardous (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately) drugs from not following special handling requirements potentially leading to health complications. 1. During a medication pass (med pass) observation on 5/5/26 at 8:21 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were safely stored for five of 37 sampled residents (Resident 145, Resident 155, Resident 46, Resident 156 and Resident 67) when:A medicine cup containing three medicine tablets was found on top of the nightstand in Resident 145's room;A box of eyedrop (liquid medication applied to the eye surface to treat dryness, allergies, or infections) was observed on top of Resident 155's nightstand;Four pink plastic ampoules were observed on top of Resident 46's nightstand;An unlabeled medication cup containing white powder was observed on top of Resident 156's bedside table; andThree syringes of normal saline (NS, mixture of water and salt) were observed on top of Resident 67's nightstand. These failures decreased the facility's potential to safely store medications for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program was effective when the facility had not identified and developed corrective action plans for issues related to administration of IV (Intravenous-administering medications through a needle or tube inserted into a vein) medication documentation and RNA (Restorative Nurse Assistant) services being performed daily per physician's order for a census of 154. This failure increased the risk for residents residing in the facility to have poor quality of care outcomes. During an interview on 5/8/26 at 1:54 p.m. with the Administrator (ADM), the ADM stated the facility conducts quarterly QAPI meetings. The ADM stated the committee members review Performance Improvement Projects (PIP), quality measures, and grievances. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program for a census of 154 when:Staff did not perform hand hygiene in between glove use and did not maintain clean work environment during wound care for Resident 24; Certified Nursing Assistant (CNA) 2 did not wear required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care to a resident on enhanced barrier precaution (EBP, an infection control method);Staff did not perform hand hygiene prior to assisting Resident 121 during a meal;Laundry Aide (LA) used the same apron while loading residents' dirty laundry into the washer and when moving clean linens from the washer to the dryer; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity for one of 37 sampled residents (Resident 50) when Certified Nursing Assistant 1 (CNA 1) was observed standing while assisting Resident 50 during the lunch meal in the dining room. This failure decreased the facility's potential to protect Resident 50's dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 37 sampled residents (Resident 128 & Resident 156) were given showers according to the shower schedule and personal preferences when:Resident 128 did not receive her scheduled shower for seven days; and,Resident 156 did not receive shower as scheduled. These failures contributed to Resident 128 & Resident 156 not receiving scheduled shower(s), and had a potential for negative health outcomes related to hygiene.

Inspectors wroteBased on interview and record review, the facility failed to ensure that information regarding a hospital transfer was effectively communicated to 1 of 37 sampled residents (Resident 14)'s Responsible Party (RP) when Resident 14's Notice of Proposed Transfer/ Discharge was not completed. This failure had the potential to result in Resident 14's RP to not be informed of reason for transfer and right to return to facility. A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility in November 2015 with multiple diagnoses including anoxic brain damage (lack of oxygen to the brain causing brain cell death), dysphagia (difficulty swallowing), and moderate protein calorie malnutrition (does not take in enough calories or protein to meet nutritional needs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a detailed approach outlining individual resident's concerns and needs, and the care and services needed to meet their needs) addressing resident's non-compliance (refusals) of showers was developed for one of 37 sampled residents (Resident 106). This failure resulted in Resident 106 not having clear care guidelines to the desired health outcomes of the identified issues and had the potential to impact Resident 106's health. A review of Resident 106's clinical record indicated the facility admitted the resident in 2023 with multiple diagnoses, which included absence of right leg below knee, history of falling, and depression. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nutritional needs and interventions were identified to mitigate weight loss for 2 of 37 sampled residents (Resident 7 and Resident 14) when quarterly nutritional risk assessments by a Registered Dietitian (RD) were not completed. This failure had the potential for Resident 7 and Resident 14's nutritional needs to be unmet resulting in further weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document oxygen saturation levels (amount of oxygen in the blood) for 1 of 37 sampled residents (Resident 1) when Resident 1's documented oxygen saturation level did not indicate Resident 1 was using supplemental oxygen (oxygen therapy that provides extra oxygen to breathe to maintain oxygen saturation levels). This failure resulted in documentation that was not accurate and did not reflect Resident 1's treatment needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify trauma triggers for 1 out of 37 sampled residents (Resident 7) with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This failure had the potential for Resident 7 to experience re-traumatization (re-experience/relives a traumatic event or experiences causing similar stress reactions to a new event), and possible increased symptoms such as restlessness, irritability, and social withdrawal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy per physician orders for one of three sampled residents (Resident 1) when Resident 1's oxygen liter flow (the rate supplemental oxygen is delivered) was increased and the indication for the increase was not documented. This failure had the potential for Resident 1 to have adverse effects from more oxygen than needed including lung damage and hypercapnia (high levels of carbon dioxide in the blood causing decreased oxygen to the brain that can lead to drowsiness, confusion, and coma). [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect one of four sampled residents (Resident 1) from abuse when Resident 2 inappropriately touched Resident 1. This failure had the potential for Resident 1 to feel shame and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident's right to choose their own physician was honored for one of four sampled residents (Resident 1), when the facility did not promptly act upon Resident 1's Responsible Party (RP, a person designated by the resident to make decisions on their behalf) request regarding psychiatry provider. This failure deprived Resident 1's RP from exercising her rights to participate in Resident 1's plan of care and to make informed decisions about the care and treatment for Resident 1 and had the potential to negatively impact Resident 1's care. A review of the admission record indicated the facility admitted Resident 1 in 2016 with multiple diagnoses, which included after care for cerebral infarction (stroke). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when Resident 1's blood sugar was not consistently monitored and reported to the physician. This failure increased the risk for Resident 1 to experience complications due to unrecognized low or high blood sugar level. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident/resident representative was involved in the care planning for one of three sampled residents (Resident 1) when the care plan conference was not conducted as scheduled. This failure increased the risk for not meeting the needs of Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's rights to personal privacy and confidentiality of personal medical information was maintained when a document with resident's information was left on top of the medication cart, for a census of 167. This failure had the potential to compromise the privacy of residents. During a concurrent observation and record review on 3/3/26 at 11:52 a.m. in Station 3 hallway, a document was on top of the medication cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to have the current Advance Health Care Directive (AD- legal document that gives instructions about healthcare decisions and to name someone to make decisions if unable) for one of eight sampled residents (Resident 5). This failure resulted in Resident 5's first and second Designated Agent (DA) for Power of Attorney for Health Care (POA- person who will make health care decisions for you when you cannot) not being notified by the facility of Resident 5's death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of eight sampled residents from physical abuse (Resident 1), when Resident 1 was struck on the face by Resident 2. This failure resulted in Resident 1 experiencing psychosocial distress and fear in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Care Plans were updated and documentation was complete for three of eight sampled residents (Resident 1, Resident 2, and Resident 4) when Resident 1 and Resident 2 were involved in a resident-to-resident altercation and Resident 4 reported abuse by a staff member. This failure had the potential for Resident 1, Resident 2, and Resident 4 to not receive the necessary interventions to maintain psychosocial and physical wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to protect Resident 1's right to be free from physical abuse when Resident 2 threw a cup at Resident 1's face, a deficient practice identified for one of six sampled residents reviewed for abuse. This failure caused Resident 1 to be covered with water and left a red mark on his cheek.

Inspectors wroteBased on interview and record review, the facility failed to protect the rights to be free from abuse for 1 of 5 sampled residents (Resident 2) when Resident 3 witnessed Resident 1 grab and place Resident 2's hand on Resident 1's groin. This failure resulted in Resident 2 not being free from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required regulatory timeframe for two of five sampled residents (Resident 1 and Resident 2) when an allegation of abuse was reported to the California Department of Public Health (CDPH), three days after staff were made aware of the allegation. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services for six out of 13 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6), when showers were not given as scheduled. This failure decreased the facility's potential to protect residents' rights, maintain well-being, and prevent skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents ' (Resident1) rights to be free from abuse was protected when Resident 2 was witnessed by staff fondling Resident 1 ' s breasts without her consent. This failure resulted in Resident 1 not free from abuse by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained in a consistent manner for a census of 171 when: 1. A discontinued bottle of a controlled medication, a medication with high potential for abuse or addiction, was not stored with other controlled medications in the Director of Nursing's (DON) office and it did not have a count sheet; and, 2. Unused and discontinued controlled medications were not removed from the active medication storage areas for destruction. These failures had the potential for medication error and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's medication storage policies and procedures, when: 1. Expired pharmaceutical products were found inside medication carts, 3 in the front station and 4 in the back station; 2. Loose pills were found in 2 medication carts; 3. Blister pack found behind drawer in the bottom of medication cart 3 front station; and, 4. Medications were found at the bedside in Random Resident 1's room and Resident 37's room. These failures had the potential for drug diversion as well as residents receiving ineffective concentrations of prescribed medications.

Inspectors wrote2. During a medication administration observation on 3/18/25 at 8:22 a.m., LN 2 was observed administering medication on a medication cart that was not cleaned of white powder residue from a previously crushed medication. During an interview with LN 2 on 3/18/25 at 8:25 a.m., she indicated that the white powder was a crushed Acetaminophen (medication used for pain) tablet and medication cart surfaces should be cleaned prior to administration of medications. During an interview with DON on 3/20/25 at 11:35 a.m., she stated the expectation was to keep surfaces clean, clean with appropriate cleaner, and don't wipe the medication on the floor. A review of the facility policy statement titled, Storage of Medication, revised September 2024, indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one of 35 sampled residents (Resident 147), when the Minimum Data Set (MDS- a federally mandated resident assessment tool) did not accurately reflect Resident 147's use of tobacco. This failure decreased the facility's potential to identify Resident 147's care needs.

Inspectors wroteBased on interview and record review, the facility failed to follow up with the Preadmission Screening and Resident Review (PASRR, a federal process that ensures people with serious mental illness, intellectual or developmental disabilities are not inappropriately placed in nursing facilities and received the most appropriate care and services) for one of 25 sampled residents (Resident 117). This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 117.

Inspectors wrote4. A review of Resident 147's admission record indicated Resident 147 was admitted to the facility in August 2024 with diagnoses including high blood pressure and generalized muscle weakness. A review of Resident 147's MDS, dated [DATE], indicated Resident 147's Brief Interview for Mental Status (BIMS,tests memory and recall) score was 12 out of 15 which indicated mild memory impairment. During an interview on 3/19/25 at 10:15 a.m., with Resident 147, Resident 147 stated that he smoked a cigar once daily. During an interview on 3/20/25 at 9:46 a.m., with CNA 3, CNA 3 confirmed Resident 147 was a smoker and CNA 3 had observed Resident 147 smoking. During a record review of Resident 147's care plan (CP), dated 3/3/25, there was no documented smoking CP for Resident 147. [...]

Inspectors wroteBased on Observation, interview, and record review, the facility failed to ensure assistance with use of hearing aids was provided for 1 of 35 sample residents (Resident 94). This failure had the potential to result in Resident 94's care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 14) out of a census of 171, was assisted with nail care as part of their Activities of Daily Living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when Resident 14 had long fingernails with brownish substance underneath the fingernails on her left hand. This failure had the potential to result in Resident 14 acquiring an infection through harboring residue and bacteria.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was within reach for two residents (Resident 14 and Resident 227), for a census of 171. This failure had the potential to result in unmet care needs and placed the residents at risk for safety.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide 80 square feet of space per residence in rooms 302, 303, 304, 305, 306, 309, 310, 312, and 314. This failure decreased the facility's potential to provide adequate personal space for the residents in these rooms for a census of 171. During review of the document addressed to the California Department of Public Health (Department), dated 3/19/2025, the following rooms are observed not to meet the minimum space requirement for each resident: Room Resident Sq. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of eight sampled residents (Resident 8) right to return to the facility following hospitalization. This failure resulted in Resident 8 facing an unanticipated discharge from the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of three sampled residents (Resident 1) when a physician's order for Prednisone (a steroid medication used to reduce the inflammation in the body) was not followed upon resident's discharge from the hospital and when the facility did not follow up on another physician's instructions to lower the Prednisone dose. These failures resulted in Resident's 1 to receive Prednisone for an additional 17 days which increased the potential to affect Resident 1's health and experienced unwanted side-effects such as oral thrush (infection in the mouth) and fluid buildup in the body (when fluid isn't removed from the body by normal methods).

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of 4 sampled residents (Resident 2) from abuse when Resident 1 hit Resident 2 on the arm during an altercation. This failure resulted in Resident 2 sustaining a skin tear on the left forearm and for Resident 2 to potentially experience emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three sampled residents (Resident 1's) Resident Representative (RP) with access to the resident's medical records timely. This failure resulted in delay of RP receiving Resident 1's medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was given a 30-day discharge notice. This failure reduced the facility's potential to provide Resident 1 enough time to appeal the discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was promoted for one of three residents (Resident 1) when the resident did not receive routine baths per their bathing schedule. This failure resulted in Resident 1 feeling upset, angry, and dirty.

Inspectors wroteBased on observation, interview and record review, the facility failed to have an effective pest control program and maintain sanitary conditions in the kitchen, when several flies were seen inside the kitchen and food preparation area and, small worm like creatures were observed crawling on the kitchen floor underneath the dishwashing sink. These failures had the potential to result in foodborne illnesses or inflict harm to 170 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store foods according to professional standards for food safety when: 1. There were opened and unlabeled food items in the freezer and the cooking area; 2. A yellow cutting board was stained with black markings; and, 3. [NAME] puffy substances were observed at the bottom of the steel storage racks in the dry storage room. These failures had the potential to increase the risk of foodborne illnesses for a total of 164 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Resident's personal and medical information was protected when the dietary tray tickets were discarded in the general trash. This failure had the potential to compromise the privacy and confidentiality of the 164 residents receiving facility prepared meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medications (medications with high potential for abuse or addiction) when random controlled medication audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for three out of three residents (Residents 30, 119 and 120) did not reconcile to indicate the medications were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and the potential for abuse, misuse, and diversion of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor, and document side effects and behaviors associated with psychotropic medications (medications that affect the mind, emotions, and behavior) use for one of 33 sampled residents (Resident 91). This failure had the potential for unnecessary use of psychotropic medications for Resident 91.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened biological's (medicine derived from living organisms), eye drops, and ear drops were dated once opened, appropriately labeled to correctly identify which resident they were for, and were not available for resident use past their expiration date for a census of 164. These failures had the potential for residents to receive medications with unsafe or reduced potency from improper storage or being used past their expiration date.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow and maintain an effective infection prevention and control program for a census of 164 when : 1. There were unsanitary conditions in the laundry room; 2. Unlabeled urinals were found in shared bathrooms of two rooms and in Resident 15's shared bathroom; 3. An unlabeled jug of distilled water was found on the floor inside Resident 119's room; and 4. Staff personal belongings and a cigarette lighter were found on medication carts. These failures had the potential to spread germs and cause infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rights were maintained for one (Resident 31) out of a census of 164 when the RP (responsible party) was not given the opportunity to consent for a placement of PPD skin test (a test to help diagnose tuberculosis (TB), a lung illness) and an addition of D-Mannose (a supplement to help prevent urinary tract infections) to Resident 31's medication profile. This failure resulted in Resident 31's RP not being able to participate in the plan of care and Resident 31 receiving medical treatment without proper consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of 33 sampled residents' (Resident 106) property from loss when Resident 106's inventory sheet was not signed and not verified for accuracy. This failure resulted in Resident 106 losing her phone and feeling sad, and decreased the facility's capabilities on protecting residents' properties from loss.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive person-centered care plan for one of 33 sampled residents (Resident 126) when Resident 126's care plan did not address the order for nectar thick fluid consistency when it was initiated. This failure had the potential for the order to be missed and not implemented.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for Resident 59 in a census of 167 when Licensed Nurse (LN) 12 and LN 13 failed to report to the facility's physician about Resident 59's verbalization to commit suicide. This failure had the potential to adversely affect Resident 59's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 33 sampled residents (Resident 43) received care in accordance with professional standards when Resident 43 was not turned and repositioned every two hours as ordered. This failure increased Resident 43's risk to develop skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services for two of 33 sampled residents (Resident 126 and Resident 153) when: 1. Resident 126's order for thickened fluid consistency was not implemented; and 2. The fluid restriction order was not maintained and accurately monitored for Resident 153. These failures had the potential to increase the risk of aspiration for Resident 126 and to delay the improvement of Resident 153's bilateral lower extremity edema (swelling caused by trapped fluid in the body tissue).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician's order to change the oxygen cannula (a small, flexible tube with two open prongs used to deliver supplemental oxygen to the nose) was followed for two of 33 sampled residents (Resident 27 and Resident 99). This failure increased the potential for residents to have infections (growth of germs) caused by oxygen tubing not being changed as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the fluid intake for one of 33 sampled residents (Resident 27) was accurately monitored and communicated to the physician. This failure increased the potential for Resident 27 to experience fluid overload (too much fluid in the body).

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of 33 sampled residents (Resident 10) was free from unnecessary medication when Resident 10's antibiotic (medication used to treat infections caused by bacteria) was renewed without documented clinical rationale. This failure resulted in unnecessary medication for Resident 10, which had the potential for increased risk of antibiotic resistance and exposure to side effects associated with prolonged antibiotic use.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide 80 square feet of space per resident in rooms 302, 303, 304, 305, 306, 307, 309, 310, 312, and 314. This failure decreased the facility's potential to provide adequate personal space for the residents in these rooms for a census of 164.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 9 sampled residents (Resident 7) when her fall risk care plan was not consistently implemented. This failure had the potential to increase the risks for falls for Resident 7 who sustained multiple falls in the past.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of medical records for one resident (Resident 1) of three sampled residents when Resident 1's Responsible Party (RP) did not receive the medical record via electronic mail (email) as requested. This failure decreased the facility's potential to provide resident medical records consistent with state laws and regulations.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing services in accordance with professional standards for one of three sampled residents (Resident 1), when the facility did not follow a dental provider post operative instructions after Resident 1 had a dental surgical procedure and had her teeth extracted. In addition, the facility failed to assess Resident 1 for oral discomfort and/or pain, bleeding, and other complications associated with teeth extraction. This failure resulted in Resident 1's experiencing oral pain and had the potential to cause bleeding and other complications related to the oral surgical procedure.

Inspectors wroteBased on interview and record review the facility failed to monitor and report changes for one of four sampled residents (Resident 1) when: 1. Resident 1 was not monitored by nursing staff every day after a fall, and; 2. Medical Providers (MP) were not made aware by staff of abnormal vital signs (measurements of the body's most basic functions) and mood when Resident 1 had a documented low temperature and oxygen saturation (a measure of the oxygenation in the blood). These failures had the potential to delay care and decreased the potential for medical interventions to prevent a worsening change of condition.