Westwood Post Acute Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision in accordance with the resident's assessed needs and individualized care plans (CP- a document outlining a detailed approach customized to an individual resident's need and care) for one of three sampled residents, Resident 3. This deficient practice resulted in Resident 3 walking out of the room unsupervised and sustain a fall with injury requiring a surgical intervention on 6/17/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility's failed to:1. Implement standard precautions (a set of infection control practices used to prevent the transmission of diseases) in the provision of care for one out of one sampled resident (Resident 96).2. Check and the temperatures for two of two facility laundry dryers (Dryer 1 and Dryer 2) to ensure the dryers temperature was at 180 degrees according to the facility's policy and procedures (P&P) titled, Laundry - Sorting, Washing & Drying. The facility's census was 84 residents.3. Ensure one of one sampled resident (Resident 82's) nasal cannula (NC- flexible plastic tubing used to deliver oxygen directly through the nose) was not left on the floor. Resident 82 was dependent on oxygen therapy. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff completely closed the bedside privacy/dignity curtain during care that fully closed provide privacy and maintain the a resident's dignity (basic right to be valued, respected, and treated as a human being) during activities of daily living care (ADL - activities such as bathing, dressing and toileting a person performs daily) for one of one sampled resident (Resident 41) according to the facility's policy and procedures (P&P) tiled Resident Rights -Quality of Life, reviewed and approved 6/10/2026. A a result, Resident 41's private parts were visible from the hallway violating Resident 41's rights to be treated with privacy and dignity with the potential for the resident to suffer lowered self esteem and feel undignified.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the residents and/or responsible party (RP) had the ability to consent to use of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) treatment prior to initiating treatment for two of three sampled residents (Resident 7 and 9). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications for Residents 7 and 9.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of one sampled residents (Resident 88) room was free of clutter, safe, clean, comfortable, homelike environment according to the facility's policy and procedure (P&P) titled Resident Rooms and Environment reviewed and approved 6/10/2026. Resident 88's room floor was cluttered with multiple several clothing and stuffed animal on the floor. This deficient practice resulted in an environment that was unsafe, unclean, uncomfortable, not homelike and had the potential for infection.

Inspectors wroteBased on observation, interview, and record review, for three of eight sampled residents (Residents 72, 74, and 78), the facility failed to implement its policy and procedures (P&P) titled, Grievances and Complaints, with a review date of 6/10/2026. Inform/educate the residents that the Administrator (Admin) is the facility's appointed Grievance Officer (GO - a resident advocate who handles residents/complaints, ensures the residents rights are respected, and investigates the residents' concerns without fear of retaliation) to oversee the facility grievance process (a formal complaint that is investigated by the facility). Address Residents 72, 74, and 78's concerns and grievances. This failure resulted in: Resident 72 felt scared of backlash (a strong, usually negative reaction by a large group of people to a change, event, or decision) if the resident made a complaint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure staff did not store a black pouch with seven credits cards inside Medication cart [NAME] (MC-W) drawer for to one of one sampled resident (Resident 105).2. Returned the credit cards and black pouch to Resident 105 when the facility discharged Resident 105 on 4/10/2026 according to the facility's policy and procedures (P&P) titled, admission and Discharge - Personal Property dated 10/2/2025. This deficient practice increased the risk for unauthorized access and use of Resident 105's credit cards resulted in exposing Resident 105 to the risk of financial abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident specific information for payment and quality measures were electronically transmitted to the Internet Quality Improvement Evaluation System (IQIES - digital filing cabinet and grading system that allows healthcare facilities like nursing homes and home health agencies to report patient data to the government) Assessment Submission and Processing (ASAP) System, an minimum data set (MDS - a standardized health checklist used by Medicare- or Medicaid-certified nursing homes) record that passes Centers for Medicare and Medicaid Services (CMS - a United States of America federal government agency that oversees public health insurance programs) standard edits and is accepted into the system, within 14 days of the final completion date, or event date in the case of Entry and Death in Facility situations, of the [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) out of three sampled residents (Residents 9) preadmission screening and annual resident review (PASARR 1- a federally mandated assessment process ensuring that individuals with mental illnesses, are not inappropriately placed in Medicaid-certified nursing facilities and receive the specialized care they need) assessment screening was accurately completed to determine the facility's ability to provide the necessary care and appropriate services for the resident. This deficient practice placed Resident 9 at risk to not receive the necessary care and appropriate services necessary for the resident to reach the highest practicable physical, mental and psychological well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review (PASRR -a detailed assessment that determines if someone with a mental illness [like serious mental illness, intellectual disability, or related conditions] needs specialized services and the most appropriate place to receive them) level I assessment for residents identified with mental disorder was accurately completed for one of one sampled resident (Resident 2), in accordance with the facility's policy and procedures (P&P) titled admission Screening Resident Review (PASRR) with review and approval date of 6/10/2026. This deficient practice had the potential to negatively affect the appropriate care and services rendered to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of one sampled resident (Resident 2) in accordance with the facility's policy and procedures (P&P) titled Person-Centered Care Planning with review and approval date of 6/10/2026, by failing ensure that resident 2 had a person-centered care plan. This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure that professional standards of practice met resident care and needs for one of one sampled resident (Resident 38) in accordance with the facility's policy and procedures (P&P) titled Physician Orders with review and approval date of 6/10/2026 when physicians orders were not carried out as instructed for resident follow up with the Orthopedic (a medical specialty that emphasizes the treatment of injuries and diseases of the musculoskeletal system) doctor and a Computed tomography (CT - a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body showing detailed images of any part of the body) scan post antibiotic therapy was ordered or scheduled. [...]

Inspectors wroteBased on observation, interview and record review, for one out of two sampled residents (Resident 95), the facility failed to clearly label the enteral feeding (a medical process that delivers a specialized liquid nutrient formula directly into the stomach or small intestine) bottle with the date and time staff started/hanged the enteral feeding, and label the hydration infusion (water flush) bag with the flow rate, and with the date and time the hydration infusion (water flush) bag was started/hang and the correct infusion rate for the enteral feeding. This deficient practice had the potential for the resident not receive desirable nutritional and hydration needs/goals and for the facility staff not to know when to next change the enteral feeding bottle for Resident 95.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Medication Storage in the Facility reviewed 2024 and Medication ordering and receiving from pharmacy reviewed 2024 for two of three Medication Carts (MC-E and MC-W), by failing to dispose:1) One unlabeled/unidentified orange oval shaped pill found in one drawer of MC-E2) Three unlabeled/unidentified (a pink oval shaped pill, a small yellow round pill and a yellow capsule) were found in one drawer of MC-W.This failure had the potential to cause medication errors and harm to the residents. Findings; During a concurrent observation and interview with Registered Nurse (RN) 1 on 6/17/2026 at 9:19 am, in the facility hallway, one drawer in MC-E had an unlabeled/unidentified one orange oval shaped pill. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label and date food items in the patient refrigerator for 81 of 86 medically compromised residents who receive nutrition orally in the facility according to the facility's policy and procedures (P&P) titled Food brought in by Visitors dated 05/22/2025. This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 81 medically compromised residents who receive nutrition orally in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility staff performed Restorative Nursing Session (RNS - guided practice with a nurse or nursing assistant to help a patient maintain or regain their ability to do everyday tasks) services according to physician orders, dated 1/27/2026 and the facility's policy and procedure (P&P) tiled Resident Restorative Nursing Program Guidelines, effective date 5/26/2026 for one of one sampled resident (Resident 4). This deficient practice had the potential to result in ineffective RNA services, development of contractures (is a permanent or prolonged shortening of muscles, tendons, ligaments or skin to become stiff and rigid) and further decline in Resident 4's ability to perform everyday tasks.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and safeguard the residents personal and medical records for one of one sampled residents (Resident 38) according to the facility's policy and procedure (P&P), titled, Storage and Destruction of the Designated Record Set, reviewed and approved 6/10/2026. Resident 38's intravenous (IV -within a vein) Vancomycin (antibiotic/medication used to treat infections) bag with a label intact containing Resident 38's protected health information (PHI - information maintained in the same data set that could identify the individual). This deficient practice violated health insurance portability and accountability (HIPPA - strict standards for managing, transmitting, and storing protected health information) and right to privacy for Resident 38. Findings; [...]

Inspectors wroteBased on observations, interview, and record review, the facility staff failed to develop a base line individualized care plan addressing identified resident's behavior and refusal of wound care for one of four sampled residents, Resident 2. This deficient practice had the potential for delayed assessment and provision of necessary care and services for Resident 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's request for a lateral transfer to another skilled nursing facility closer to the resident's family was assisted and facilitated. The facility staff failed to assist a resident with required insurance changes to allow accepting facilities to process admission for one of four sampled residents Resident 2. This failure had resulted in an unreasonable delay and impeded Resident 2's right to transfer to the facility of choice. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to remove expired food from refrigerator as per their policy. This deficient practice had the potential to cause food borne illness. During an observation on 12/15/2025 at 1:46 p.m., in the refrigerator, there was a bin of tomatoes with a use by date of 12/12/2025 and a bin of wilted (limp) celery with no date. During a review of the produce storage guidelines, the guidelines indicated tomatoes can be stored for 1 week at room temperature and celery can be stored in the refrigerator for one week. During an interview on 12/15/2025 at 1:48 p.m. with the dietary supervisor (DS), the DS stated all deliveries are labeled upon receipt and should be disposed of past the use by date. [...]

Inspectors wroteAMENDEDBased on observation and interview in the facility failed to ensure:1. The kitchen stove top did not have dried food and debris.2. Food was labelled and/or dated. This deficient practice had the potential to result in food borne illness to residents who consumed food prepared by the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of three sample residents, Resident 3, had call lights (a call system a resident uses to call for help from staff) within reach while in bed as required to maintain immediate access to staff assistance. This deficient practice had the potential to place Resident 3 at risk for unmet care needs and delayed response by staff to emergencies.

Inspectors wroteBased on interview and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped) in accordance with the American Heart Association (AHA - organization dedicated to fighting heart disease and stroke) guideline for one of three sampled residents (Resident 1). On [DATE] at 4:08 P.M., Resident 1 was found unresponsive (when a person is not reacting to shaking, touch, sound, or verbal commands and may or may not continue breathing) in the patio, facility staff transferred Resident 1 to his room to start the CPR. As a result, Los Angeles Fire Department (LAFD) paramedics (healthcare professional/s trained to provide advanced emergency medical care, often in pre-hospital settings) pronounced Resident 1 dead in the facility on [DATE] at 4:34 P.M.

Inspectors wroteBased on record review and interview for one of three sampled residents, Resident 1. The facility failed to: 1. Ensure regular re-evaluation of discharge plan. 2. Coordinate with resident representative (RR) in the discharge planning process. 3. Ensure Resident 1 was discharge with supply of hydroxyzine (medication given for itching). 4. Ensure the assisted living facility (ALF- a residential care facility the provides non-medical care and supervision for senior who need assistance with daily living activities but don ' t require 24-hour nursing care) was notified that Resident 1 had a gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) during discharge planning process. 5. Ensure Resident 1 was set up with home health. 6. Follow up with Resident 1 post discharge. [...]

Inspectors wroteBased on interview and record review for two of three sampled residents (Resident 1 and Resident 3). The facility failed to: 1. Develop a care plan for the gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for Resident 1. 2. Develop a discharge care plan for Resident 3. This deficient practice placed Resident 1 at risk of infection and placed Resident 3 at risk of inaccurate discharge plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 5) had a call light the resident was able to use within reach. This failure resulted in Resident 5's inability to call staff for assistance due to inability to push the call light button.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) their care plan intervention of Low Air Loss (LAL-mattress designed to prevent and treat pressure injuries by reducing moisture and heat buildup using a system of inflated air cells that continuously circulate air) mattress was implemented. This failure resulted in a decline in Resident 1's pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the medical record documentation of ADLs was accurate and complete for one of five sampled residents (Resident 1). This failure resulted in an inaccurate and incomplete medical record for the resident.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents Resident 1 was free from medication errors: 1. By failing to follow physician ' s order to hold the medication Empagliflozin (brand name Jardiance- medication that treats type 2 diabetes by helping kidneys remove sugar from blood), LVN1 attempted to administer the medication on 4/8/2024 am shift. 2. LVN1 left the medication Empagliflozin/Jardiance unattended. This deficient practice had the potential harm by putting Resident 1 at risk of low blood sugar level.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat twelve of twelve sampled residents in need of feeding assistance, with respect and dignity by calling them feeders, and keeping a list of their room numbers labeling them Feeders for the purposes of making the assignments. Sampled residents included (21), (16), (247), (30), (6), (53), (8), (36), (248), (37), (54), and (19). This deficient practice caused or had the potential to cause depression (a prolonged feeling of sadness, hopelessness, or loss of interest in activities).

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' clinical records were complete and updated with advance directives (a 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) for three out of four sampled residents (Residents 18, 50 and 246) by failing to maintain an accurate and current copy of the resident's advance directives in the resident's clinical record. This failure resulted in or had the potential to cause conflict with te wishes regarding health care for Residents 18, 50 and 246.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an unknown Liaison (a person who helps different groups communicate and work together) did not have access and retained the medical records for one of six residents (Resident 48). This failure resulted in a Health Insurance Portability and Accountability Act (HIPPA - is a federal law enacted in 1996 that aims to protect individuals' health information and ensure the continuity of their health insurance coverage) violation of medical records for Resident 48.

Inspectors wroteBased on interview and record review, facility failed to accurately and completely document diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) education in the resident's chart for one of four sampled residents (Resident 76). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 76.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure that one of ten sampled residents (Resident 38) was assessed for medication self-administration. This deficient practice had the potential to cause over medication or harm to Resident 38.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a safe, comfortable, and a homelike environment for one out of four residents sampled (Resident 64). This failure resulted: 1. Resident 64 not having access to hot water for grooming and personal hygiene. 2. Resident 64 got wet from the splashing water faucet to get wet. Also, this Failure paused the potential for accidents and falls with injuries Cross Reference F689.

Inspectors wroteBased on observation, interview, and record review, for one of six residents (Resident 48) the facility failed to arrange and ensure a safe discharge home for Resident 48 through discharge planning prior and conduct interdisciplinay team (IDT - A team brings together professionals from various disciplines to collaborate and provide holistic care for patients) meeting with Resident 48 and the resident's family prior to discharging Resident 48 from the facility for 1 of 6 residents (Resident 48). This failure resulted in unsafe discharge home for Resident 48 and Family Member (FM) 1 making sudden arrangements and life style changes at home to accommodate Resident 48. FM 1 wasvery upset, cried, was uncomfortable, and felt helpless.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan in accordance with the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care Planning revised 3/21/2025 for one of four sampled residents (Resident 55). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 55.

Inspectors wroteBased on interview and record review, the facility failed to conduct an interdisciplinary team meeting (IDT - a group of experts from several different fields) for one of three sampled residents (Resident 55), per the facility's policy. This deficient practice had the potential to result in Resident 55's care needs not being met comprehensively when resident/resident's representative were not involved in developing a care plan and making decisions for Resident 55.

Inspectors wroteBased on interview, and record review, for one of three sampled resident (Resident 56), the facility failed to: 1. Ensure that on 319/2025 at 4:30 PM, Resident 56 received Humalog KwikPen insulin (a rapid-acting hormone for regulating blood sugar levels) 10 units (a unit of measurement) subcutaneous (SQ- injecting into the fatty tissue layer just beneath the skin) for a blood sugar (BS) of 541 milligrams per deciliter (mg/dL- unit of measurement. Normal BS is 70mg/dL-120 mg/dL) and notify a physician of the high BS according to physician order. 2. Licensed Vocational Nurse (LVN) 6 did not administer Humalog KwikPen before checking Resident 56's BS before meals on 3/20/2025 at 11:30 AM and on 3/20/2025 at 4:30 PM. 2. LVN 6 checked Resident 56's BS before administering Humalog KwikPen insulin 5 units SQ on 3/20/2025 at 10:30 PM. 3. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure a safe, comfortable, and a homelike environment for one out of four residents sampled (Resident 64). This failure paused the potential for accidents and falls with injuries for Resident 64 Cross Reference F584.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 55) received appropriate treatment and services. This deficient had the potential to cause inadequate nutrition and possible infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Liaison did not have access and retain the medical records and identifiable documents for one of six residents (Resident 48). This failure resulted in the facility violating the Health Insurance Portability and Accountability Act of 1996 standards for privacy of individually identifiable Health Information (HIPPA privacy standards) for Resident 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccines were offered and/or administered to two of five sampled residents (Resident 58, and Resident 71) per facility policy. This deficient practice had the potential for Resident 58 and Resident 71 to acquire and/or transmit PNA infection to other residents in the facility and possible hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination was offered and/or administered for two of five sampled residents (Resident 58, and Resident 71) per facility policy and procedures. This deficient practice placed Resident 58, and Resident 71 at risk for COVID-19 infection and/or hospitalization.

Inspectors wroteAmendedBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 33 out of the 37 resident rooms. Those 33 rooms consist of two beds each. This deficient practice had the potential to result in inadequate safe and useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promote or enhanced resident ' s dignity and respect by failing to ensure staff was not standing over resident while feeding for two out of two sampled residents (Resident 5 and Resident 8). This deficient practice had the potential to cause psychosocial harm to the resident and could violate resident ' s right to be treated with dignity and respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident ' s call light (a device used to notify the nurse that the resident needs assistance) were answered promptly for one of three sampled residents (Resident 4). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of three sampled residents (Resident 1) by failing to ensure that a comprehensive (CP) was developed after Resident 1 had a fall incident with injury on 12/5/24. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, Resident 1 by failing to implement facility ' s policy and procedure (P&P) titled, Death of a Resident when Resident 1 expired on [DATE]. This deficient practice resulted in incomplete assessment and documentation required per facility ' s policy and procedure upon death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of two sampled residents (Resident 2 and Resident 4) by failing to ensure a physician ' s order was in place for oxygen (O2) therapy for Resident 4 and the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) was changed for Resident 2 and Resident 4 per facility ' s policy. These deficient practices had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record review the facility failed to protect two of four sampled residents (Resident 1 and Resident 2) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings. This deficient practice resulted in Resident 1 ' s missing clothes and Resident 2 ' s missing neck pillows.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise and monitor one out of three sampled Residents (Resident 1) to prevent falls. Resident 1 had a history of recurrent falls and was assessed as a high risk for falls. As a result, on 11/08/2024 at 8pm, Resident 1's suffered a fall from a wheelchair and sustained a left eyebrow laceration (skin tear) with bleeding and swelling. Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation and management. GACH applied three sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) on Resident 1's laceration. The fall placed Resident at increased risk for severe injury and or death.

Inspectors wroteBased on observation, interviews, and record review the facility failed provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of diseases for three out of four residents (Residents 1, 3, and 4) by failing to ensure: 1. To assess Residents 1, 3 and 4 ' s skin rash. 2. To place Residents 1, 3, and 4 on contact precautions due to the presence of an unidentified rash. 3. Failing to notify Resident 3's physician that the treatments ordered were not effective. These deficient practices had the potential to spread infection to the residents, visitors, and the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality by failing to: 1. Ensure Resident 1 had an abdominal binder to prevent her Gastrostomy Tube (often called a G tube, is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) from frequently being dislodged. 2. Ensure that Resident 1 was sent to General Acute Care Hospital (GACH) timely after her G tube was dislodged. 3. Ensure Resident 1 ' s abdominal assessment (a physical examination of the abdomen that includes inspection, auscultation, percussion, and palpation. It's a key part of a patient's physical exam and can help determine the cause of gastrointestinal or genitourinary issues) was performed 3 times a week. 4. ensure staff were trained or in-serviced on the signs and symptoms of bowel impaction. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of six sampled residents (Resident 6). This deficient practice violated Resident 6 ' s right to have grievances addressed.

Inspectors wroteBased on interview and record review, the facility failed to effectively manage a resident's pain by not following physician ' s order for one of two sampled residents (Resident 2). This deficient practice resulted in Resident 2 experienced unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of three sampled residents, Resident 1 by failing to implement facility ' s policy and procedures (P&P) titled, Death of a Resident when Resident 1 expired on [DATE]. This deficient practice placed Resident 1 in incomplete assessment and documentation required per facility ' s policy and procedure upon death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection control policy and procedure (P&P) and implement the comprehensive care plan for one of two sampled resident (Resident 4) by failing to provide education about transmission-based precaution and offer personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) use to the visitor of Resident 4. This deficient practice had the potential to spread infection to the residents, visitors, and the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to change and update to a menu to meet the nutritional needs for one of the three sampled residents (Resident 1) who was identified as being at a risk for unplanned weight loss. This deficient practice resulted in Resident 1 experiencing significant weight loss (unplanned weight loss) and was transferred to General Acute Care Hospital (GACH) for further evaluation and treatment. Cross reference F755.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to implement its own policies and procedure by failing to ensure the accurate administration of a medication Darolutamide 300 milligrams [mg] (Nubeqa- a prescription medicine used to treat adults with prostate cancer that has spread to other parts of the body and responds to medical or surgical treatment that lowers testosterone (metastatic hormone-sensitive prostate cancer [a disease that occurs when malignant cells grow in the prostate gland, which is located below the bladder in the male reproductive system] or mHSPC), for one out of three sampled residents (Resident 1) for . This deficient practice had the potential to result in Resident 1 ' s prostate cancer worsening.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the licensed nurse notified the physician about the change of condition (COC- a sudden or acute deviation from a patient's baseline that may lead to complications or death if left untreated) for one out of three sampled residents (Resident 1) by: - Failing to report to the physician about resident 1 ' s abdominal distention (when the abdomen is abnormally swollen outward and can be caused by a buildup of fluid, tissue, or digestive contents, or by gas and may be related to constipation) on [DATE]. - Failing report the inconsistent bowel movement (BM). This deficient practice had the potential to result in Resident 1 being constipated and lead to bowel obstruction (occurs when the lumen of the bowel becomes either partially or completely blocked. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, the resident who was assessed as high risk for falls, did not fall four times and sustained injuries for one of three sampled residents (Resident 1). The facility failed to: 1. Provide Resident 1 with a full-time 1:1 sitter (one to one staff that is immediately at hand to help prevent a fall or redirect a patient from engaging in a harmful act) per a care plan titled, High Risk for Injury/Accidents and Falls, dated 11/24/23, to prevent the resident from falling on 1/25/2024, 4/11/24, 4/28/24, and 5/7/2024 and sustain injuries. Resident 1 was provided with the 1:1 sitter only after Resident fall on 5/7/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe and functional area to prevent the infestation of roaches and provide a clean environment in one of one staff ' s breakroom in the facility. This deficient practice had the potential to negatively impact the psychosocial wellbeing of the staffs.

Inspectors wroteBased on interview and record review, the facility failed to promote dignity and respect for two of seven sampled residents (Residents 200 and 21) by failing to: 1. Conduct a personal property inventory upon admission for Resident 200. 2. Ensure staff did not speak in a language not understood by Resident 21 in the presence of the resident. These deficient practices had the potential to decrease self-worth, create anxiety and powerlessness, and affect the physical, mental, and psychological wellbeing of Residents 200 and 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comfortable sound levels at night for three of eight sampled residents (Residents 52, 246, and 83). This deficient practice resulted in Residents 52, 83 and 246 not being able to sleep undisturbed through the night, compromising the health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to conduct Pre-admission Screening Resident Review (PASRR -an evaluation to determine if an individual has a serious mental illness, intellectual disability, developmental disability, or related condition) for two of three sampled residents (Residents 33 and 60). This deficient practice had the potential to result in inappropriate care and services necessary for Residents 33 and 60.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label food in accordance with professional standards and facility policy to ensure the safety of food service by failing to: 1. Label and date food items stored in the kitchen refrigerator. 2. Discard expired food stored in the resident's refrigerator. 3. Provide a refrigerator for the residents to store food brought in from the outside. 4. Label and date food items stored on the shelves in the kitchen. 5. Discard expired food items stored on the kitchen shelves. 6. Label and date food items stored in the resident's refrigerator. Those deficient practices placed residents with compromised health status at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' rights for one of one sampled resident (Resident 60) by failing to obtain an out on pass physician's order for Resident 60. This deficient practice had the potential to affect Resident 60's psychosocial well-being, optimal functioning leading to low sense of self-worth and self-esteem.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a comprehensive assessment for pre-admission screening Resident Review (PASRR -an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) for one of three sampled residents (Resident 33). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 33.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to active diagnoses, were accurately documented to reflect the resident's psychiatric/mood disorder (related to mental illness and its treatment) for one of three sampled residents (Resident 12). This deficient practice had the potential to negatively affect the plan of care and delivery of necessary care and services for Resident 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 22), who was unable to carry out activities of daily living (ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), received the necessary services to maintain good personal oral hygiene. This deficient practice resulted in Resident 22 having dry and cracked lips and had the potential to cause dental caries (tooth decay), bleeding, thrush (overgrowth of yeast in mouth), oral infection, leading to unnecessary hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin care and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per physician's orders for one of three sampled residents (Resident 89) on Low Air Loss Mattresses (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) by failing to ensure the LALM was set to Resident 89's weight. This deficient practice had the potential to delay healing and increased the risk of developing new pressure injuries, worsening of existing pressure injuries, and complications related to pressure injuries for Resident 89.

Inspectors wroteBased on observation, interview and record review, the facility failed implement its policy and procedure in accordance with the care plan of the resident to monitor signs and symptoms of urinary tract infection (UTI- an infection involving any part of the urinary system, including urethra, bladder, and kidney) for one of six sampled residents (Resident 35). This deficient practice resulted in Resident 35 developing sediment (matter that settles to the bottom of a liquid) in urine and a UTI.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff met the skills and staff competency evaluation requirements. This deficient practice had the potential for a knowledge, training, and certification deficit among the nursing staff, leading to inadequate or delayed resident care.

Inspectors wroteBased on observation, interviews and record reviews, The facility failed to label medications for one of six sampled residents (Resident 89). This deficient practice had the potential to result in unsafe medication administration. in Resident 89 ingesting unlabeled medication, use expired medications and cause confusion about what the medication is.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 33 out of the 36 resident rooms. Those 33 rooms consist of two beds each. This deficient practice had the potential to result in inadequate safe and useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident ' s right were honored and implemented accordingly to his decision on health care treatment for one of five sampled residents, Resident 1. This deficient practice violated resident ' s right to make an informed decision and resulted to failure in the delivery of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect residents ' rights for one of three residents (Resident 1). As a result, the facility discontinued a physician for Resident 1 ' s to go out on pass (permission of a patient to leave the hospital in a specified time).

Inspectors wroteBased on interview and record review, for one of three residents (Resident 1), the facility failed to conduct a root cause analysis for falls for Resident 1. As a result, Resident 1 suffered two falls and had the potential to experience additional falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) had a change of condition (COC, a change in a resident's mental, psychosocial, or physical functioning that requires a change in the resident's comprehensive plan of care) for significant weight loss completed timely. This failure resulted in Resident 1 not being referred to the Registered Dietician (RD) for possible new weight loss interventions and delayed the monitoring of the weight loss or gain for three weeks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Residents 2, 3, 4, & 5) who were smokers were supervised when smoking. The facility was aware Resident 2, 3, 4 and 5 used a personal lighter to light a cigarette unattended. This deficient practice had the potential for fire related accidents in the facility among residents, staffs and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a functioning call light for one of three sampled residents (Resident 3). This deficient practice had the potential to result in a delay in meeting the resident 's need for assistance and treatment including the resident 's pain management.