Westwood Post Acute

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the care and services needed as ordered by physicians to one of three sampled residents, (Resident 1), when the facility did not arrange transportation for Resident 1 for an outside appointment which resulted in Resident 1 missing her appointment. This failure had the potential to compromise Resident 1's health and well-being. During a review of Resident 1 's face sheet (document that summarizes a person's information such as medical history) indicated Resident 1 was admitted to the facility with diagnoses including migraine, unspecified not intractable, without status migrainosus (a standard headache migraine without warning flashes (aura), the attack has not lasted past 72 hours, and pain responds to normal medical treatments) and low back pain, unspecified. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement their abuse policy and procedure for one of three sampled residents (Resident 1) when the facility did not report Resident 1's allegation of abuse (someone who changes her diaper sexually assaulted her) to required agencies (California Department of Public Health [CDPH] and Long-Term Care Ombudsman) timely. This failure had the potential to compromise the safety of Resident 1 in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to protect a resident's right to be free from sexual abuse when Certified Nursing Assistant (CNA) C witnessed Resident 5 placed his male genital (penis) inside Resident 4's mouth. This failure resulted in nonconsensual sexual act that put Resident 4 at risk for sexually transmitted infection, injury and psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged violation involving sexual abuse was reported immediately when the Unit Manager (UM) failed to immediately report a witnessed sexual abuse on Resident 4 by Resident 5 on 4/3/26. The UM failed to call the Police, notify the State Agency (CDPH - California Department of Public Health) and the Ombudsman on 4/3/26 when the sexual abuse occurred and within the timeframe defined by regulations. This failure resulted in delayed investigation of the abuse allegation and put residents at risk of possible violations such as abuse, neglect, exploitation or mistreatment with or without injuries.

Inspectors wroteBased on interview and record review, the facility failed to facilitate a person-centered care planning meetings for one of one resident (Resident 1) when the interdisciplinary team (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) missed to hold Resident 1's quarterly care conferences (a regular, formal meeting [usually quarterly] where the resident, their family, and the nursing home staff meet to review the resident's health, discuss goals, and adjust their care plan). This failure had the potential for unmet goals, choices and preferences for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide services according to professional standards for one of one resident (Resident 1) when licensed nurses had no documentation of Resident 1's use and care of sequential compression device (SCD - a pair of inflatable leg wraps connected to a machine that acts as a massager for the legs to prevent blood clots while inactive, a compression therapy) and there was no care plan (a summary of a person's health conditions, goals, specific care needs, and current treatments) developed for the SCD's use. These failures resulted in multiple fluid filled blisters (a small, raised bubble on the skin filled with clear, water liquid, blood, or pus) and pain on Resident 1's bilateral (affecting two sides) lower extremities (legs).

Inspectors wroteBased on interview and record review, the facility failed to ensure the availability of medication for one out of 3 sampled residents (Resident 1) when Resident 1 missed four doses of Fidaxomicin Oral Tablet (treats diarrhea caused by bacteria) from 1/29/26 to 1/30/26 when the facility staff did not send the Prior Authorization for High Cost Medication to the Pharmacy on time. The failure had the potential for untreated or worsening of medical conditions for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of five sample residents (Resident 1) was provided with needed care and services in accordance with resident's preferences when Resident 1 was asking for help but was not attended by staff during shift change. This failure had the potential to put Resident 1 at risk for physical and psychosocial harm. During a concurrent observation and interview on 4/9/26 at 2:53 p.m. outside Resident 1's room, Resident 1 can be heard shouting Help while the door was open. Staff were observed doing reports for the shift change. Certified Nurse Aide (CNA) A was using a tablet attached to the wall along the hallway of Resident 1's room. Multiple staff were observed to pass by Resident 1's room without checking on Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain grooming and personal care to one of two sampled residents (Resident 1) when Resident 1's skin in bilateral (involving or affecting two side, or parts) lower legs especially the heel areas were very white, and scaly (a symptom where the top layer of skin becomes, dry, rough, and sheds in flakes, often resembling fish scales) due to dryness, and her fingernails and toenails were long. These failures had the potential to affect Resident 1's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices was implemented when licensed vocational nurse E (LVN E) used a non-dedicated battery-operated blood pressure apparatus (BP app - a manual or automated devices intended for general, or multi-user rather than a specialized, single patient, or permanently installed in the room) to Resident 1 who was on Contact Precaution [infection control measures used in healthcare to prevent the spread of germs passed by direct touching (patient) or indirect touching (contaminated surfaces/equipment)], and did not clean and sanitize (a substance designed to reduce or eliminate germs, bacteria, and microorganisms on surfaces or skin to safe levels) the equipment before leaving the room. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services according to professional standards for one of two sampled residents (Resident 1) when registered nurse A (RN A) and licensed vocational nurse B (LVN B) re-inserted Resident 1's gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) without proper training and demonstration of competency in this procedure, using a bigger size of GT and did not have a detailed confirmation of GT placement (verifying if the tube is in the stomach using methods like checking for stomach contents, easy rotation of the tube, and lack of leakage. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement Resident 1's insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep) care plan. This failure had the potential to not meet care needs for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a visible and audible alarm activated by a call button) alternative (call bell) is available for one of three residents (Resident 1). This deficient practice had the potential to result in a delay in meeting Resident 1's needs for toileting and activities of daily livingDuring a concurrent observation and interview on 8/15/25 at 11:35 a.m., in Resident 1's room. Resident 1 was lying in her bed. There was an overbed table next to her bed and there was no alternative for the call light. Resident 1 stated the call light is not working for two weeks now. Resident 1 stated she doesn't have the call bells. Resident 1 further stated it's okay to ask the staff to check if she has a call bell at bedside. Resident 1 stated she has to call the front desk for help, and it takes time. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received therapy services as ordered by a physician. The failure decreased the facility's potential to ensure Resident 2 reached his highest rehabilitation potential. During an interview on 7/18/25 at 12:49p.m., with Resident 2, he stated issue with the manpower in therapy, they are skipping on therapy to 4x a week and then until 3x a week. Resident 2 stated the staff said they don't have enough staff in therapy when he spoke to one of the therapists. Resident 2 stated the therapy is helping with self-care and he needed more therapy, and he ran out of Medicare (a health insurance program) days. During a review of Resident 2's admission record on 7/18/2025, dated 5/29/2025 indicated Resident 2 was admitted to the facility with diagnosis including muscle weakness. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to implement their abuse policy and procedure for one of one resident (Resident 1) when the facility did not report Resident 1's injury of unknown source. This failure resulted in Resident 1's injury of unknown source not reported to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their infection prevention practices were implemented when: 1. A urinary catheter (a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drainage bag touched the floor; 2. Hand hygiene (the practice of cleaning your hands to prevent the spread of germs and illness) and the removal/change of isolation gowns (a type of personal protective equipment (PPE) used in healthcare settings to protect healthcare personnel and patients from the spread of infection or illness, particularly from contact with blood and body fluids) was not completed between tasks; 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and privacy was upheld for residents when: 1. Resident 23's privacy curtain was not fully drawn when Resident 23 removed her facility gown; 2. Assistant Director of Nursing (ADON) A referred to Resident's clothing protector as bibs in front of approximately 15 residents; and, 3. Certified Nursing Assistant (CNA) B was observed to assist feeding Resident 194 while standing over her. These failures had the potential for adverse effects on the psychosocial well-being and health of Resident 23, Resident 194 and approximately 14 others residents in the dining room during mealtime.

Inspectors wroteBased on interview and record review the facility failed to protect two of 36 sampled residents (Resident 21 & Resident 445) from physical abuse. When: 1. Resident 231 was observed to physically hit Resident 21 2. Resident 231 was observed to physically hit Resident 445 These failures resulted in Resident 21 & Resident 445 to be physically abused by Resident 231.

Inspectors wroteBased on interview, and record review, the facility failed to notify The Office of the State Long -Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) of resident's transfer or discharge in a timely manner when: 1. The Office of the State LTC Ombudsman was not notified for 16 of 51 discharged residents (Residents 151, 166, 237, 233, 183, 408, 103, 409, 410, 411, 404, 412, 414, 415, 416, and 417); and, 2. The facility's notification to The Office of the State LTC Ombudsman for six of 51 discharged residents (Residents 418, 419, 420, 421, 404, 422, and 423) were submitted late. These failures resulted in the State LTC Ombudsman not being informed in a timely manner and removed the opportunity for the State LTC Ombudsman (LTC-O) to advocate on resident's behalf.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to prevent and/or heal pressure ulcers (damage to the skin or underlying tissue as a result of prolonged pressure) for two residents (Residents 190 and 546) when staff did not turn and reposition the residents every two hours. This failure had the potential to delay wound healing, worsening pressure ulcers and the development of new pressure ulcers for Resident 190 and Resident 546.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for three of 12 sampled residents (residents on oxygen therapy) when: 1. Residents 28's and Resident 152's O2 concentrator's (a device which concentrates the oxygen from ambient air) filters had some grayish substance build up; and, 2. Resident 212 was administered the wrong dosage of oxygen. These deficient practices had the potential for Residents 28, 152, and 212 to have complications related to improper treatment while receiving O2 therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff had appropriate competencies to provide nursing care for one (Resident 192) out of seven sampled residents when Resident 192 was not assisted by staff when requested. This failure had the potential for physical injury and psychosocial distress.

Inspectors wroteBased on observation, interview and record review the facility failed to post direct care staffing numbers, and nursing staff responsible for direct care to residents in a prominent place in each of four nursing stations of the facility. This failure had the potential for residents and visitors not knowing the accurate number of hours of staff working and which staff were scheduled and available to care for their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accurate accountability of controlled medications (medication with a high potential for abuse and addiction) when: 1. Controlled medications were signed out of the Controlled Drug Record (CDR, an inventory or count sheet) but not documented on the medication administration record (MAR) as administered for four out of five residents (Residents 15, 61, 81, and 114). 2. Records of wasted controlled medications did not contain the co-signature from another nurse for four randomly selected residents (Resident 81, 294, 295, and 296) as per facility policy and procedures. These failures had the potential result to the misuse and abuse of controlled substance medications.

Inspectors wroteDuring an interview on 4/14/25 at 10:55 a.m. with Resident 192, Resident 192 stated food was terrible, and vegetables were mushy. During an interview on 4/15/25 at 9:34 a.m. with Resident 61, Resident 61 stated food did not taste good. During a concurrent dining observation and interview on 4/15/25 at 12:13 p.m. with Resident 192, Resident 192 stated carrot was mushy. Resident 192 did not eat all the carrots on her plate. During a concurrent dining observation and interview on 4/15/25 at 1:00 p.m. with Resident 25 stated food lacked flavor. Resident 25 also stated carrots were overcooked. Resident 25 pressed his fork on the carrots on his plate and were easily mashed. During a lunch test tray conducted on 4/16/25 at 1:32 p.m. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure evening snacks were offered to all residents. This failure had the potential to affect the nutritional and psychosocial wellbeing of residents who may receive snacks at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation and food storage methods, according to standards of practice and facility policy when: 1. Frozen [NAME] (a type of fish) was stored in the freezer without use by date and opened cereals without open and used by dates. 2. Metal container was stored wet. 3. Pureed food was prepared in a sink These failures had the potential to expose residents to contaminants that could cause foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate and systematically organized documentation in accordance with accepted professional standards and practices for one of five sampled residents (residents with peek-a-boo mittens [a type of mitten, often used in healthcare settings, that have a flap on the top that allows for easy inspection of the hand without removing the mitten and designed to prevent patients from removing medical equipment attached to them]) when Resident 23's used of peek-a-boo mitten was not documented in all her weekly summaries (a concise report that provides an overview of a resident's care and progress over the past week). This failure resulted an inaccurate and inappropriate documentation of Resident 23's weekly summaries.

Inspectors wroteBased on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality to one of 36 sampled residents (Residents 23) and one unsampled resident (Resident 397) when Resident 23 and Resident 397's personal information and care instructions were posted in the room visible to roommate's visitors. This failure had the potential to compromise resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASARR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was accurately completed for one of 36 sampled residents (Resident 28). This failure had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plan for one of 36 sampled residents (Resident 23) when a care plan for Resident 23's behavior of pulling off her clothes or facility gown was not developed and implemented. This failure had the potential to result in not having to identify the specific care and services necessary to meet Resident 23's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 241) out of one sampled resident received treatment and care in accordance with professional standards of practice when Resident 241's vital signs were not checked and due medications were not given. This failure had the potential to compromise Resident 241's physical health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary podiatry services for one of 36 sampled residents (Resident 215) when the toenails were longer than Resident preferred causing pain and concern for ingrown toenails or infection. This failure had the potential to affect the resident's foot health and contribute to injury and/or infection. Review of Resident 215's clinical records indicated Resident 215 had multiple diagnoses including hemiplegia (a symptom that involves the loss of the ability to move on one-side of body) and hemiparesis (one-sided weakness), and diabetes (high blood sugar). Resident 215's cognitive function is intact Review of Resident 215's order summary, dated 11/14/24, indicated Resident 215 may have Podiatry evaluation, Tx, and follow up every 61 days and prn (as needed). During an interview on 4/14/25 at 9:40 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 out of 36 sampled residents (Residents 105) was free from unnecessary medications when there was inadequate monitoring for the resident's vitamin B12 (a supplement to treat vitamin B12 deficiency) and vitamin D (an essential vitamin that your body uses for normal bone development and maintenance) level as ordered. This resulted in inadequate monitoring related to medication management for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and orderly discharge for one (Resident 1) out of 2 residents when Resident 1 was discharged without established home health as ordered by the physician. This failure had the potential to put Resident 1 in danger upon returning to his home without a proper care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards for one of three sampled residents (Resident1) when: 1. Resident 1's baseline care plan (a basic initial care plan created for a patient upon admission to a healthcare facility, outlining the most essential care needs and instructions until a more comprehensive care plan can be developed) related to dysphagia (difficulty in swallowing) and tube feeding (a flexible tube inserted through nose or belly to provide nutrients) were not developed in a timely manner; 2. Nurses did not notify dietitian or the attending physician when Resident 1 was admitted with tube feeding formula not in facility stocks; and 3. Licensed vocational nurse A (LVN A) signed the IV ATB administered by a registered nurse (RN) for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the pharmaceutical services to meet the needs of residents when: 1. Licensed nurses did not administer the ordered intravenous (IV, to deliver a medication into a vein) antibiotic (ATB, a medicine that inhibits the growth of or destroys bacteria) in a timely manner as documented for three of three sampled residents (Residents 1, 2 and 3); and 2. Licensed nurse used other resident's normal saline (NS - a sterile solution containing 0.9% sodium chloride [salt] in water) to mix the Vancomycin for one of three sampled residents (Resident 1). These failures resulted in medication not given to Resident's 1, 2, and 3 as per their scheduled time and had a potential to affect their health and safety.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician promptly for one of one resident (Resident 1) when Physical Therapist (PT, who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion) A did not communicate with Resident 1's charge nurse when the resident fell during her physical therapy session and sustained minor injuries. This failure had the potential to result in a delay of assessment and possible treatment to Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to promote respect and dignity for one of one resident (Resident 1) when Social Services (SS) A told Resident 1 she would call 911 (a telephone number for emergencies) for a 5150 (the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) assessment when the resident was trying to advocate for her roommate. This failure had the potential to negatively affect the resident's dignity and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure services provided met professional standards of practice when a licensed nurse (LN) did not ensure medications were taken for one of one sampled resident (Resident 1). For Resident 1 LN did not observe medications were taken after giving the medications to the Resident. This finding had the potential to compromise Resident 1's health and safety. [...]

Inspectors wroteBased on interviews and record review facility failed to maintain respect and dignity for one out of five sampled Residents (Resident 2) when staff tried to interfere on his right to use his power wheelchair. This failure resulted in psychosocial distress to Resident 2 and his family.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide a safe, functional, and comfortable environment for residents and staff when: 1. Room (RM) A and B TV cables were dangling; 2. RM B ' s bathroom light fixture was without cover; 3. RM B and C ' s baseboards were missing paint and dusty; 4. RM D and E ' s dresser (furniture with several drawers used to store clothes) drawer handles were broken; and 5. RM F, G, H, I, J, and K ' s dresser drawers were peeling with plastic layer hanging. This failure had the potential to affect the safety of the staff and the comfort of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their bed rails (side rails, safety rails and grab/assist bars) policy for 34 of 35 sampled residents (Residents 117, 121, 159, 104, 89, 65, 134, 175, 99, 3, 125, 49, 43, 101, 26, 53, 81, 131, 11, 78, 105, 149, 617, 618, 6, 9, 32, 172, 154, 206, 1016, 35, 193, and 79). The survey team expanded the sample and identified that a total of 198 residents had bed rails. The facility failed to follow their bed rails policy when: 1. There was no documentation that alternatives were attempted prior to installing bed rails for 198 of 198 residents; 2. There was no documentation that risks and benefits were explained to the residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails for 198 of 198 residents; 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure: 1. Resident 35 with a wheat allergy received nourishing and palatable meals to meet their needs; 2. The overall day-to-day food and nutrition services operations were carried out in a safe and sanitary manner for food service, preparation, storage, and delivery; equipment sanitation; kitchen staff competency; ineffective pest control; and acceptable parameters of nutrition care to prevent significant and severe resident weight loss for two sampled residents (Residents 104 and 175), according to standards of practice and facility policy. These deficient practices led to 231 residents being exposed to these improper conditions, specifically 197 residents who consume food from the kitchen. Cross reference F692, F802, F804, F812, F813, F908, and F925

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the kitchen staff had the competencies and training to perform their job duties and tasks according to standards of practice and facility policy when: 1. A Dietary Aide did not safely store milk on the trayline served to residents. 2. Two Dietary Aides did not know how to correctly test the sanitizer in the three-compartment sink. These failures had the potential to expose 197 residents who receive food from the kitchen to contamination from food and chemicals that may harm their health and nutrition status.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the recipes were followed, and food was served at a safe and palatable temperature according to facility policy and resident complaints. These failures had the potential to negatively affect the nutritional status due to poor food intake of 197 residents on a therapeutic diet and who may consume a snack from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Food preparation equipment and utensils were not maintained clean and/or in good condition including: a. Two of three ice machines; b. Pans, pitchers, mixing bowls; c. A meat slicer; d. An industrial can opener; e. Cutting boards; f. Knives; and g. A microwave. 2. Kitchen storage equipment were not clean and/or in good repair including: a. Food storage racks in the walk-in refrigerator were rusty; b. Drawers holding food preparation/serving utensils; c. A rack holding food preparation equipment/utensils; d. A cart holding items such as cooking oil and gloves; and e. A cart holding clean cutlery. 3. Floor drains were not maintained clean; 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have a policy pertaining to the safe storage of resident food brought in from the outside. This failure had the potential to expose 197 residents who consume food, to contamination from the unsafe storage of the resident's food from outside stored in three facility refrigerators, including an employee refrigerator where resident and employee food were comingled.

Inspectors wrote3. Review of Resident 177's admission Record indicated he was admitted to the facility on [DATE]. During an observation and interview with Certified Nursing Assistant II (CNA II) on 11/13/23 at 12:20 p.m., Resident 177 had two urinals on his bed side table; they were dirty and had dry yellow residue around their necks. CNA II stated Resident 177 used the two urinals and confirmed they were dirty. CNA II stated the urinal should be washed every two hours and changed if it was dirty. During an interview with the Infection Preventionist (IP) on 11/17/23 at 8:59 a.m., he stated the urinal should be washed after it was used. The resident's urinal should be kept clean and changed if it was dirty. Review of the facility's policy, Cleaning and Disinfecting Non-Critical Resident-Care Items, dated 6/2011, indicated . Steps in the Procedure: . Measuring Graduates/Urinals: 1. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain kitchen equipment in safe operating condition when: 1. Water was dripping onto the floor from the dish machine; 2. A sink/garbage disposal drain was leaking; and 3. A three-compartment sink did not have appropriate drain plugs to allow the sinks to be filled with water. The failure to maintain the equipment working in the way intended had the potential to lead to contamination of food, utensils, and equipment for 197 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the facility: 1. Free of flies; and 2. In a manner to keep pests from entering the kitchen. This failure had the potential to result in pest transferred disease to residents for a census of 231.

Inspectors wroteReview of Resident 9's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including spondylosis (condition caused by aging and wear and tear on the spine) and diabetes. Review of Resident 9's POLST, dated 6/6/22 indicated the section regarding advance directives was left blank. There was no documented evidence that indicated Resident 9 had an advance directive or that advance directives were discussed with the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for 11 of 35 sampled residents (Residents 265, 32, 172, 175, 99, 195, 159, 617, 11, 618, and 105) when: 1. For Resident 265, a speech therapy consult was not done per physician order; 2. For Resident 32, staff provided the resident with salt while she was on a physician ordered no added salt diet; 3. For Resident 172, a licensed nurse failed to properly administer the resident's tube feeding and there was no order or documented assessments for the use of peek a boo hand mittens; 4. For Resident 175, there was no documented assessments or care plan for the use of peek a boo hand mittens and order for use of peek a boo mittens was not followed as indicated. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide parameters to maintain acceptable nutrition status for a planned weight loss regimen for one sampled resident (Resident 175) with severe weight loss; and 2. Complete a nutrition assessment for one of six sampled residents (Residents 104) with significant weight loss. These failures had the potential to result in undesirable and/or avoidable weight loss for two out of six sampled residents with facility reported significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for seven of eight randomly selected residents (Residents 94, 111, 131, 168, 184, 189 and 193). Two of two randomly selected medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift. Medications for disposal in the medication storage room and one medication cart were not rendered unusable and irretrievable. Five of 13 emergency kits (e-kit; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened multi-dose medications and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date, expired medications were not available for resident use, single resident over-the-counter (OTC) products were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for, vaccine refrigerator temperatures were monitored daily, labeling of pharmacy-dispensed gabapentin with an expiration date, and storage of medication separate from resident food items. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity for four of 35 residents (28, 53, 104, and 162) when 1. Certified Nursing Assistant W (CNA W) and Certified Nursing Assistant X (CNA X) did not maintain privacy when providing care for Resident 28 and 53; and 2. Certified Nursing Assistant Z (CNA Z) and Certified Nursing Assistant CC (CNA CC) were standing while feeding Resident 162 and Resident 104. These failures had the potential to cause embarrassment and feeling low self-esteem for the residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 81). Failure to assess had the potential to compromise the facility's ability to provide resident-centered care plan interventions.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 35 sampled residents (Residents 117 and 121). This failure had the potential to compromise the facility's ability to provide resident-centered care plan interventions.

Inspectors wroteBased on interview, and record review, the facility failed to coordinate the Preadmission Screening and Resident Review (PASARR, is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for one of 35 residents (Resident 32) when a PASARR was not done after Resident 32 had a significant change in condition. This failure resulted in Resident 32 not being evaluated and placed the resident at risk for not receiving the appropriate care or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement interventions to maintain the ability to communicate for one of 35 sampled residents (Resident 104). This failure had the potential to result in Resident 104's needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an activity program was provided to one of 35 sampled residents (Resident 618). This failure had the potential to affect the overall well-being and quality of life of the resident.

Inspectors wrote4. Review of Resident 265's clinical record indicated she was admitted to the facility with diagnoses including contracture of muscle (tightening or shortening of the muscle which can result in loss of joint mobility and joint deformity) and dysphagia (difficulty swallowing). Review of Resident 265's Skin Assessment, dated 7/19/23 indicated the resident had two trochanter (a bony prominence on the thigh bone close to the hip) pressure ulcers. The assessment also indicated the MD was notified and received new treatment orders and wound consult. Review of Resident 265's orders, indicated an order, dated 7/19/23, Wound MD consult for L [left] trochanter wound. Review of Resident 265's Skin Assessment, dated 8/4/23 indicated the two small trochanter pressure ulcers merged into one wound. The assessment also indicated, Notified MD. New order for Wound care consult ordered . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents (Resident 618) had and was wearing his hearing aids (small devices placed in the ear to amplify sound). This failure had the potential to compromise the residents' health, ability to relate to others, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 35 sampled residents (Residents 265, 65, 149) with limited mobility were provided appropriate treatment and services: 1. For Resident 265 and 65, there was no documentation that restorative nursing services (RNA, restorative care for individuals recovering from illnesses or injuries) were provided as ordered; 2. For Resident 149, there was no care plan or interventions developed to address her arthritis (inflammation or swelling in one or more joints that can result in stiffness and pain). These failures had the potential to result in decreases in mobility and complications for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 35 residents (Resident 175), with an indwelling catheter (a small, flexible tube that can inserted through the bladder to drain into a urine bag) received care consistent with professional standards when there was no evidence of an order for a indwelling catheter, there was no evidence of catheter care, and there was no evidence of a care plan a indwelling catheter. These failures had the potential to put Resident 175 at risk of not receiving the interventions necessary to maintain their highest level of well-being and at risk of a urinary infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for three of 35 sampled residents (Residents 209, 617, and 105) when: 1. For Resident 209 and 617, staff failed to ensure oxygen was administered as specified in the physician's order; and 2. For Resident 617, staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and safety.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure a resident receiving hemodialysis (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) treatment received care consistent with professional standards for one of 35 sampled residents (Resident 49) when Resident 49's dialysis access site was incorrectly assessed and documented upon Resident 49's return to the facility and the care plan for dialysis was not specific to Resident 49's hemodialysis. This failure had the risk of causing the resident health complications.

Inspectors wroteBased on interview and record review, the facility failed to act upon the Consultant Pharmacist's (CP) monthly medication regimen reviews (MRR) for two of five sampled residents (Residents 6 and 175). This failure had the potential for unsafe medication use for these residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of five sampled residents (Resident 6 and 175) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 6 received carbamazepine (Tegretol, anticonvulsant; medication used to treat seizures, a medical condition in the brain causing stiffness, twitching or limpness), lamotrigine (Lamictal, anticonvulsant medication) and benztropine (anticholinergics, medication to treatment tremors or movement disorder) without clinical indications for use; [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 5.71% when four medication errors occurred out of 70 opportunities during the medication administration observation for four out of eight residents (Resident 1016, 206, 103 and 109). The failure resulted in medications not given according to the physician's orders and had the potential for residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on interview and record review, the facility failed to serve foods that accommodated residents' food allergies for one of 35 sampled residents (Resident 35). Resident 35, who was allergic to mushrooms and wheat products was served mushrooms and wheat products on two separate occasions. This deficient practice had the potential to cause severe allergic reactions and cause harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice for one resident (Resident 1) when: 1. There was no documentation that the facility communicated with the dialysis center to check on the resident ' s well-being when the resident did not return as anticipated after dialysis treatment (a treatment for people whose kidneys are failing), and 2. There was no documentation that the facility assisted the resident ' s transportation arrangement when it was cancelled. These failures had the potential to compromise the resident ' s health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents (Resident 1) when: 1. The facility did not follow their own policy for diabetes (blood sugar higher than normal) management, and 2. The care plan for diabetes was not developed. These failures had the potential to compromise residents' care and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure services was provided to meet professional standard of practice for Resident 1 when the licensed nurses (LNs) did not initial and document the time, level of pain, and effectiveness of the medication given for pain. This failure may affect the health and safety of Resident 1.

Inspectors wroteThe facility failed to ensure residents were free of accidents and hazards for one of two sampled residents (Resident 1) when: 1. Staff did not develop and/or implement resident-centered interventions to prevent falls, and 2. Care Support Team Members (CSTM) were not supervised by their supervisor during resident care. These failures resulted not prevent further falls for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders regarding pressure ulcer order treatment for sacrum (bone in the lower back ), implement the care plan intervention regard pressure ulcer (PU, injury to the skin and the underlying tissue resulting from prolonged pressure on the skin, complete the weekly skin assessment, and conduct interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) meeting to discuss Resident 1's PU condition and progress for one of three sampled residents (1) when: 1. Facility did not follow the acute hospital discharge order for low air loss (LAL, a type of therapy mattress designed to help prevent and treat pressure wounds) and avoiding the use of adult absorbent brief for Resident 1's wound management. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a safe and sanitary condition when: 1. Fifteen of fifteen medication carts (Med Carts 1-15) had multi-colored and sticky substances; medication pills were spilled inside the med carts; med carts stored expired medications; med carts stored unlabeled medications; med carts had improperly stored medications; and 2. Three of five medication rooms (Med Rooms E, D, and B) stored staff's personal items; the medication refrigerator temperatures in two med rooms (Med Rooms D and B) were out of range; and the refrigerator temperature log was incomplete for one med room (Med Room E); These failures had the potential for the residents to receive used, contaminated, and/or deteriorated medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Nurse staff did not follow infection control practices during medication passes (med pass, nurse administered the medications to residents per physician's order) for four of nine observed residents (Residents 114, 151, 30, and 72). 2. Housekeeping staff did not follow infection control practices when cleaning residents' rooms; 3. An outdated gastric tube (GT, tube inserted through the abdomen into the stomach to deliver nutrition, hydration and medication) syringe (tube with a nozzle and piston used to suck and eject liquid) was not discarded for Resident 126; 4. Surgical masks were not stored properly for Residents 30, 33 and 75; a nasal cannula was not stored properly for Resident 16; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain dignity and privacy for five of 33 sampled residents (Residents 102, 73, 36, 143 and 66) and one non-sampled resident (Resident 72). For Residents 102, 73, 36, 143 and 66, staff provided feeding assistance while standing over the residents. For Resident 72, staff did not provide privacy during the finger stick blood sugar check (FSBG, medical device is used to prick the resident's fingertip to collect a blood sample and test the blood sugar level). These failures to maintain dignity may impact the residents' quality of life and lower residents' self-esteem.

Inspectors wrote8. The clinical record for Resident 100 was reviewed. He was admitted on [DATE] with diagnoses including cerebral edema and acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). His care plan included behavior episodes of undressing self and pulling trach tubing. His physician orders included, Behavior Monitoring: document number of episodes per shift of target behavior (specify) 1. Undressing self, 2. Pulling trach tubing, date started [DATE]. A record review of the behavior monitoring record per the above order for [DATE], indicated the licensed nurses on all shifts were charting YES or NO answers to the record instead of monitoring how many times behavior 1 or 2 occurred. During an interview on [DATE] at 12:55 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted on the medication administration record (MAR) and the Controlled Drug Record (CDR) for two randomly selected residents (Residents 6 and 7). The facility failed to ensure the controlled substance was disposed properly for one randomly selected resident (Resident 91). Nurse staff stored Resident 569's opened controlled medication in medication cart 12 (Med cart 12). These failures had the potential to result in residents not getting the controlled medications per physician's order and potential to cause misusing and abusing the controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ dietary staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to check the dish machine's sanitizer correctly; 2. Dietary staff did not know how to check the quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes) at three compartment sinks area (3 sinks used to manually sanitize dishes with quaternary sanitizer); 3. Dietary staff did not know how to calibrate the temperature thermometers correctly; the registered dietitian (RD) did not know how to calibrate the temperature thermometers correctly; and 4. RD was not aware how kitchen function and did not supervise the kitchen or provide in-service to dietary staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. Toaster had multi-colored substances; 3. Refrigerator (fridge) had multi-colored substance; 4. Electrical pipes on the wall near the kitchen table had black sticky substance; 5. The can opener had multi-colored substances; 6. Multi-colored substance noted on the top of the dish washer; 7. There was no space (air gap) between dish machine (same as dish washer) and food preparation sink drain pipes and floor sink drain; 8. Two of three ice machines (Ice machine B and C) had black substance at the interior and exterior of the ice machines; 9. There was no evidence that the facility identified and addressed the multiple out of range dish machine temperatures (per the dish machine temperature log). [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain sanitary conditions for the dumpsters when four of five dumpsters were overflowed with disposable food plates and utensils, dumspters were not covered with lids, garbage bags were overflowed from the side of the dumpster, and used gloves were on the ground next to the dumpsters. These failures had potential to harbor or feed the pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and resident plan of care for one non-sampled resident (Resident 150) by not ensuring an adaptive device was available for Resident 150. Resident 150's eyeglasses were kept in the social service office instead of by the bedside. This deficient practice had the potential to delay provision of services and could have resulted in the resident's needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 140) was free from physical restraints when staff placed both of Resident 140's feet into a single pressure relief boot (device strapped to the foot in order to reduce pressure on the heels). This practice impaired Resident 140's ability to move both lower extremities (feet and legs) and had the potential to negatively affect his physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy for one of two sampled residents (Resident 25) when they did not report an injury of unknown source to the Ombudsman (an advocate for the residents) and law enforcement. This failure had the potential to delay investigation of the incident in order to rule out abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards when: 1. The patio door in Station A leading to the parking lot was open; and 2. Staff did not keep the bed in its lowest position for one of six sampled residents (Resident 73) as indicated in the care plan. These failures could potentially result in serious injury to the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice and facility's policy and procedure for four of 13 sampled residents (Residents 106,111, 36 and 164) when: 1. For Residents 106, 36 and 111, facility staff failed to ensure oxygen was administered as specified in the physician's order. Residents 36 and 111 did not have the oxygen sign posted outside of the room. 2. For Resident 164, facility staff administered oxygen without a physician's order. These failures had the potential to compromise the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of eight sampled residents (Residents 5, 74 and 68) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Residents 5 and 74, staff did not monitor target behaviors (behavior intended to be reduced or eliminated by administering the psychotropic medication); and 2. For Resident 68, staff did not provide non-pharmacological interventions (interventions that do not involve the use of medications) before administering as needed (PRN) psychotropic medication. These failures had the potential to compromise the facility's ability to determine the effectiveness of the psychotropic medications. These failures also had the potential to increase the residents' risk for adverse effects from the medications.

Inspectors wroteBased on observation, interview and record review, the facility had a 19.23% medication error rate with five medication errors during 26 opportunities during the medication passes (med pass, licensed nurses administer medication to residents) for two of nine observed residents (Residents 117 and 118). This failure had the potential to jeopardize the residents' medical condition and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five resident beds (Room F beds a, b and c; Room G bed b and Room H bed c) were in safe operating condition when these five beds were found not locking properly. Two of the five beds were occupied by Residents 18 and 27. This failure can put residents and staff at risk for accidents.