White Point Care Center

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered Nurse (RN) was designated to serve as the Director of Nursing (DON) on a full-time basis. This deficient practice had the potential to negatively affect all 78 residents in the facility by impacting the overall clinical oversight, management, and quality of nursing care provided.

Inspectors wroteBased on observation and interview, the facility failed to store food in a safe and sanitary manner. The facility had (78) residents receiving oral diet. The facility failed to:1. Ensure prepared cups of orange juice, apple juice and cranberry juice were stored at the required 40 degrees Fahrenheit (F- unit of measure) while the breakfast was being plated (scooped on plates) prior to serving it to the residents.2. Ensure a container of ice cream had a use-by date (the final day a product is guaranteed to be at top quality for consumption ) after it was opened. This failure had the potential to place residents at risk for developing food borne illnesses (any illness resulting from eating contaminated/spoiled foods) and reduce the quality of food served in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were implemented for three of six sampled residents (Residents 6, 68 and 99). The facility failed to ensure:Personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms {microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents) was disposed of correctly in a closed container after providing care to Resident 68.2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 21), had a call light within reach. This failure had the potential to result in Resident 21 not being able to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for two of three sampled residents (Resident 86 and Resident 92). This failure had the potential to prevent residents or their representatives from making informed decisions about whether to receive services that may require out-of-pocket payment.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled residents (Resident 92)'s assessment entries on the Minimum Data Set (MDS- a resident assessment tool) related to hearing status and use of hearing aids was accurately documented to reflect the resident's ability to hear. This failure had the potential to negatively affect Resident 92's's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident (Resident 92) had a care plan initiated and implemented for hearing loss. This failure to provide Resident 92 with her hearing aids had the potential to negatively affect Resident 92's ability to communicate needs, participate in care and maintain psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of one sampled resident (Resident 92) with her hearing aids (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) stored in the Social Service Director's (SSD) file cabinet. This failure resulted in Resident 92 not being able to communicate effectively when spoken too.

Inspectors wroteThe facility failed to ensure a skills competency was done upon hire for the licensed staff. This failure had the potential to place residents at risk by allowing licensed staff to perform clinical tasks without confirmation they were competent to do so placing the residents at risk for staff providing care incorrectly or inconsistently and delayed recognition of changes in condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 37 and Resident 53) were free of unnecessary medication by failing to:1. Ensure Resident 37 who was receiving lorazepam (medication used to treat anxiety) was used without clinical justification, adequate monitoring and documentation.2. Ensure Resident 53 who was receiving lorazepam for anxiety and inability to sleep had documented behavior and sleep monitoring. This failure had the potential to place Resident 37 and Resident 53 at risk for unnecessary medication and adverse effects (unwanted and harmful result that can occur after taking a medication) associated with the prescribed medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of a medication error rate of 5% or greater. During a medication administration pass on 6/23/26, one licensed nurse failed to administer three prescribed medications Rena Vite (supplement), vitamin c (supplement) and zinc sulfate (supplement) to Resident (68). This resulted in a 10.34% medication error rate, based on three medication errors observed out of 29 medication opportunities.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up necessary dental services for one of four sampled residents (Residen16). This failure put Resident 16 at risk for development of tooth decay and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the terms and condition of the arbitration agreement (legally binding contract in which parties agree to resolve any future or current disputes out of court) was clearly explained to the resident/ resident representative for one of three sampled residents (Resident 90). This failure had the potential to result in Resident 90 unknowingly giving up the right to resolve any disputes with the facility through a court of law before a jury.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Certified Nursing Aides (CNA's) received the mandatory five-hour annual dementia management training. This deficient practice had the potential to effect all residents residing in the facility specifically those with dementia by placing them at risk for receiving care from staff who lack current, mandatory competency in managing behavioral expressions and cognitive (memory) decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of two resident council meetings held on 10/15/2025 and 12/17/2025, where concerns regarding timely toileting assistance on were mentioned on 10/15/2025 and delayed call light response on 12/17/2025, were documented on the Resident Council Response Form (document used by the facility to formally record and respond to concerns). This deficient practice had the potential in delaying tracking issues mentioned during the resident council meetings, resolving resident concerns, and notifying the Quality Assurance/Quality Assurance and Performance Improvement ([QA/QAPI] a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee in a timely manner to address ongoing problems.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services for one (1) of two (2) sampled residents (Resident 4). The facility failed to: 1. Reassess Resident 4 after a low blood pressure reading of 90/42 millimeter of mercury (mm/Hg unit of pressure) on 10/15/2025 at 8:29 a.m. and failing to recheck vital signs (measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate) prior to sending the resident to dialysis at approximately 11 a.m., on 10/15/2025.2. Notify the physician of a foul-smelling odor observed from Resident 4's right Achilles wound during wound care treatment on 10/14/2025. These failures had the potential to delay necessary care and treatment and increased the risk of hospitalization for Resident 4.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure a safe environment and provide adequate supervision to prevent accident for one of three sampled residents (Resident 1). The facility failed to:1. Supervise Resident 1 and Resident 2 on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio according to Resident 1 and 2's Smoking Assessment Forms.2. Secure the door leading to the smoking patio after the last scheduled smoking time at 6 p.m.3. Ensure Certified Nursing Assistants (CNA) 2 redirect Resident 2 to the resident's room instead of leaving Resident 2 unattended in the smoking patio on 10/11/2025. 4. Ensure CNA 1 was aware of Resident 1's whereabout on 10/11/2025 at 7 p.m. These failures resulted in Resident 2 throwing a plastic coffee mug at the right side of Resident 1's head. [...]

Inspectors wroteBased on interview and record review, the facility failed to report a COVID - 19 (a potentially severe illness caused by a coronavirus and characterized by fever, cough, and shortness of breath) outbreak to the California Department of Public Health (CDPH) when three residents (Residents 6, 7, and 8) tested positive for COVID-19 indicative of a facility outbreak.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to left buttock (the back of a hip that forms one of the fleshy parts on which a person sits), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of one sampled resident (Resident 1). The facility failed to: 1. Ensure the Treatment Nurse (TN 1) stopped providing Resident 1 with left buttock pressure ulcer treatment when Resident 1 had facial grimacing (a facial expression where the mouth and face are twisted, often to indicate disgust, disapproval, or pain) and was moaning during treatment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure administration of metoprolol succinate (a medication used to treat hypertension [high blood pressure] and heart conditions) extended release (ER) within 60 minutes of its scheduled time as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 05/2022, affecting one of seven sampled residents during medication administration (Resident 27). 2. Clarify and discontinue Resident 27's duplicate orders for Voltaren ([generic name - diclofenac] a medication used topically to treat osteoarthritis [pain and inflammation of joints]) topical gel, affecting one of seven sampled residents during medication administration (Resident 27). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of seven sampled residents (Residents 27 and 65). The facility failed to: a. Administer Resident 27's metoprolol succinate (a medication used to treat hypertension [high blood pressure] and heart conditions) extended release (ER) within 60 minutes of its scheduled time as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 05/2022, and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the dose on Resident 59's Lantus Solostar's ([generic name - insulin glargine] a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] used to treat high blood sugar) pharmacy label matched with the physician order in electronic medical health record (eMHR), and was labeled with an open date in accordance with manufacturer specifications, and as per facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, affecting one of seven sampled residents during medication administration. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of three sampled residents (Resident 82, Resident 48, and Resident 41) was served food that was appetizing, not bland and tasteless. This failure had the potential for Resident 82, Resident 48, and Resident 41) to lose weight.

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintain and improve safety and quality in nursing homes) committee failed to implement corrective action to the potential systemic problems identified: 1. Maintain a system to ensure call lights are answered timely. 2. Maintain a system to ensure activities of daily living are implemented. 3. Maintain a system to ensure accurate pharmaceutical services and procedures. 4. Maintain a system to ensure accurate pharmaceutical services and procedures. 5. Maintain a system free of significant medication error. 6. Maintain a system to ensure the storage and labeling of biological and medications. 7. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident (Resident 82) Minimum Data Set (MDS - a resident assessment tool) section H was coded accurately to reflect Resident 82 was not incontinent (experiencing the involuntary loss of urine or stool). This failure resulted in Resident 82's MDS being coded incorrectly and had the potential to result in a loss of dignity for Resident 82.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 78) by failing to: 1. Develop a comprehensive person-centered care plan to address Resident 78's toe infection. This failure had the potential to negatively affect the delivery of care and services to Resident 78.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 9's Ciprodex otic (ear) ([generic name - ciprofloxacin and dexamethasone] a medication used to treat ear infection and inflammation) suspension was administered per professional standards of practice and as per facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures - Ear Drop Administration, dated 05/2022, for one of seven sampled residents during medication administration (Resident 9). This failure had the potential to result in Resident 9's discomfort and untreated ear infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer treatment for left buttock Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joint}, and bones caused by prolonged pressure on the skin) on 5/8/2025, as indicated in the resident's physician orders for one of one sampled residents (Resident 1) . This deficiency had the potential for Resident 1's left buttock Stage 4 pressure ulcer to worsen, to develop new pressure injury, and had the potential to develop infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident 27) of seven sampled residents during medication administration. The facility failed to: 1. Administer Resident 27's metoprolol succinate (a medication used to treat hypertension [high blood pressure] and heart conditions) extended release (ER) within 60 minutes of its scheduled time of administration as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 05/2022. This deficient practice failed to provide medication in accordance with the physician's orders or professional standards of practice and had the potential to result in hypertension, stroke (loss of blood flow to a part of the brain) and hospitalization for Resident 27.

Inspectors wroteBased on interview and record the facility failed to ensure one of one sampled resident (Resident 85), food likes, and cultural preferences were met and honored. This failure resulted in Resident 85's not receiving food items from Resident 85's choice and preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed staff did not falsify medication administration record ([MAR] a record of all medications administered to a resident) entries as administered for medications listed below that were not available in facility, not administered or not observed as self-administered for one of seven sampled residents (Resident 27). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when Licensed Vocational Nurse (LVN) 3 failed to perform hand hygiene between resident's care and prior to entering and exiting the resident room. This deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of diseases and infection to the facility staff, residents, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set of commitments actions designed to optimize the treatments of infections while reducing the adverse events associated with antibiotic use) for one of three sampled residents (Resident 78) by prescribing an antibiotic medication (a substance used to kill bacteria and treat infections) without meeting the criteria, before being treated for toe cellulitis (a skin infection that causes swelling and redness). This failure had the potential for Resident 78 to develop antibiotic resistance (not effective to treat infection) from inappropriate antibiotic use.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of the sampled residents (Resident 82) was provided with a home-like environment, Resident 82 had a large hole in his sliding screen door. This failure had the potential to have unwanted pest entering Resident 82's room .

Inspectors wroteBased on interview and record review, the facility failed to ensure residents room temperature was comfortable and safe temperatures (71-81 degrees Fahrenheit [°F unit of measurement that is used to measure temperature ]) for one of three sampled residents. This failure had the potential to increase the risk of adverse health effects from an uncomfortable environment for the residents (Resident 3).

Inspectors wroteBased on interview and record review, the facility failed to protect the residents ' right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 slapped and punched Resident 1 in the face repeatedly on 1/17/2025. The facility failed to: 1. Developed a plan of care for Resident 2 who verbalized to staff that he does not want to have roommates, does not like noise and preferred to be alone in his room when Resident 1 was transferred to Resident 2 ' s room (unknown date). 2. The facility failed to follow policy and procedures titled Identifying Types of Abuse, revised 9/2022, which indicated, Abuse of any kind against residents is strictly prohibited. These failures resulted in Resident 2 slapped and punched Resident 1 in the face repeatedly on 1/17/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement residents' care plan interventions for one of three sampled residents (Residents 1), who had wandering (walking around slowly in a relaxed way or without any clear purpose or direction) behavior to monitor Resident 1's whereabouts. This failure resulted in Resident 1 entering her previous room after Resident 1 had alleged physical altercation (a dispute between individuals in which one or more persons sustain bodily injury arising out of the dispute) with her previous roommate.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized legal representative ([LR] a person who is legally authorized to act on behalf of another) for one of three sampled residents (Resident 1) within two working days per the facility's policy and procedure (P&P) titled, Release of Information. This deficient practice violated Resident 1 and the LR's rights to obtain a copy of the resident's medical record.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of medical records upon written request from an authorized legal representative ([LR] a person who is legally authorized to act on behalf of another) for one of three sampled residents (Resident 4) within two working days per the facility's policy and procedure (P/P) titled, Release of Information. This deficient practice violated Resident 4 and the LR's rights to obtain a copy of the resident's medical record.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure sores (a wound caused by localized area of damaged skin or tissue that can occur when prolonged pressure is applied to an area of the body) were measured and appropriate interventions were provided for a resident (Resident 1) who was a high risk for skin break down for one out of three residents. These deficient practices had the potential to cause complications of Resident 1 ' s current wounds and had the potential for Resident 1 to sustain new wounds.

Inspectors wroteBased on interview and record review, the facility failed to include the resident representative in the plan of care for one of three residents (Resident 1) when Resident 1 ' s representative was not informed of Resident 1 ' s change of condition which resulted in Resident 1 being late to his appointment. This deficient practice had the potential to violate Resident 1's right to have their representative participate in his care.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided according to professional standards of practice for one of three residents (Resident 1). The facility failed to: 1. Document the administration of seven doses of Norco [a narcotic (a drug that works in the brain to dull the sense of pain) to relieve moderate to severe pain] from 9/1/2024 through 9/3/2024 on Resident 1 ' s administration record. 2. Assess and document Resident 1 ' s pain using the pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11-point scale; 0 = no pain, 1-3 = mild pain, 4-6 =moderate pain, 7 to 9 = severe pain, and 10 = worst possible pain). 3. Assess and document the effectiveness of Norco after administration according to the facility ' s policy and procedure (P/P) titled Pain Assessment and Management. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled residents, (Resident 3) had floor mats (mat used to reduce fall related trauma if a resident gets out of bed, loses balance, and falls to the floor) at the bedside as indicated in Resident 3's care plan This deficient practice had the potential to result in injury from a fall if Resident 3 suffers a fall by the bed.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized care plan and conduct an interdisciplinary (group of professionals from different disciplines) team conference, involving the family member 1 (FM 1), to address one out of nine sampled resident's (Resident 1) refusal of examination and treatment by the podiatrist (foot specialist) and optometrist (health professional that involves examining eyes). This deficient practice resulted in a delay of needed services and had the potential to contribute to further medical problems and contribute to a negative physical wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to place floor mats (mats used to reduce fall?related trauma if a patient gets up from bed, loses balance, and falls to the floor) on both sides of one out of nine sampled resident's (Resident 1), bed as ordered by the physician and as indicated in the care plan. This deficient practice had the potential to result in severe injury if Resident 1 fell onto the floor from the bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for ywo of two sampled residents (Resident 82 and Resident 59. The facility failed to: a. Ensure Resident 82 was dry and clean and provided with privacy while only wearing diaper. This failure had the potential to affect the resident's self-worth and dignity. b. Ensure Resident 59 indwelling urinary catheter ([foley catheter]- a tube that inserted into the bladder, allowing the urine to drain freely into a collection bag, which must be strapped and/ or secured) was enclosed in a privacy bag. This failure has the potential for Resident 59 to feel embarrassed and undignified.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call light was within reach for two of three sampled residents (Resident 82 and 67). This failure had the potential for Resident 82 and 67 not able to find the call light to call for assistance when needed, and experienced loss of self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 20 and Resident 145) was provided their activities of choice (preference). This failure has the potential for Resident 20 and Resident 145 to have no mental and emotional interaction that could negatively impact their quality of life.

Inspectors wroteThe facility failed to ensure two of two sampled residents (Resident 17 and Resident 47): a. yankauer (an oral suctioning tool used in medical procedures), and suction machine tubing were dated, and b. oxygen tubing was dated and humifying water (sterile water incorporated with oxygen use to prevent irritation of the nasal passages during use of supplemental oxygen) was changed timely. These failures have the potential for the respiratory equipment to lose patency and delay delivery of care and services to Resident 17 and Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services and procedures when: a. Medications for two of two residents (Resident 39 and Resident 16), were not disposed from the medication cart after being discontinued. b. Physician's orders for fentanyl (medication to treat pain) transdermal (placed on the skin) patches were not transcribed into the Medication Administration Record (MAR) for one of one resident (Resident 14) c. Medication destruction was not followed according to the Controlled Drug Record instructions for one of one resident (Resident 14). d. Ensure to check blood pressure parameter for a resident (Resident 148) prior to administering antihypertensive medication as ordered. [...]

Inspectors wroteDuring an observation, interview, and record review the facility failed to ensure the refrigerator in the medication storage room was operating at a normal/ expected range of temperature per facility's policy (36-to-46-degree Fahrenheit {a temperature scale in which the freezing point of water is 32 degrees, and the boiling point is 212 degrees}). This failure has the potential for the medications stored in the refrigerator to lose potency (activity of the drug in terms of concentration or amount of the drug required to produce a desired effect) and efficacy (the ability of a drug to produce a desired effect) which could negatively affect the delivery of care and services to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminated food) for 93 out of 95 total residents in the facility by failing to: 1. Ensure foods were dated, labeled, and discarded before the used by date (expiration dates). 2. Monitor and document room temperature in dry storage room daily. 3. Ensure three frozen packs of ham was properly thawed in the refrigerator. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the discharge Minimum Data Set (MDS-a comprehensive assessment and care screening tool) Assessment was transmitted to Centers for Medicare and Medicaid Services (CMS) within 14 days' time frame for one of 12 sampled residents (Resident 82). This failure had the potential to the delay in identifying resident care concerns needing individualized care plan, delay in providing residents interventions necessary to provide quality care and delay in the reimbursement process.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 20) fingernails were clean and trimmed. This failure has resulted to Resident 20's right hand fingernails to have irregular edges, accumulation of dark brown substance under the fingernails and had the potential to cause infection and impaired skin integrity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 20) was provided range of motion exercises by the certified nursing assistant staff during activities of daily living (the routine activities that people do to take care of their basic needs such as eating, bathing, dressing, grooming, toileting, repositioning and transferring). This failure has the potential for Resident 20 to decline with mobility and/ or function and develop and/ or worsen contractures (fixed tightening of the muscles, tendons, ligaments, or skin that prevents normal movement) to her extremities.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 39) was free from unnecessary drugs by: Failing to assessed Resident 39 for infection before starting oral antibiotic ( drug used to treat infections caused by bacteria and other microorganisms) medication. This failure had the potential to result in Resident 39 receiving unnecessary medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of eight residents (Resident 14) was free from significant medication error by failing to administer fentanyl (medication use to treat severe pain) transdermal (on the skin) patches as ordered by the physician. This deficient practice placed the resident at risk for higher dosage of medication and respiratory depression.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for document Resident 14's records of fentanyl patch that required two signatures of licensed staff accurately and completely. This failure had the potential for non-accountability of medication and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of two sampled residents (Resident 39). Resident 39 was prescribed antibiotic ( drug used to treat infections caused by bacteria and other microorganisms) drug without meeting the criteria and prior to assessing for wound infection. This failure had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was a facility Infection Preventionist (specially trained professional who makes sure healthcare workers and residents are doing all the things they should to prevent infections [IP]) as indicated in the facility assessment for ninety of ninety residents. This deficient practice had the potential to result in the increased spread of COVID-19 (a contagious and potentially severe respiratory illness) infection in the facility and the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure gloves and alcohol-based hand sanitizers were available for use in four out of four resident rooms. These failures placed all the residents, staff, and the community at higher risk for cross contamination (transfer of harmful germs from one person, object, or place to another) and increased spread of COVID-19 (a potentially severe respiratory illness) infection in the facility and the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine the call lights were within reach and useable, for two of three sampled residents (Resident 1 and 3): A. Resident 1's call light was observed hanging over the top of lamp. B. Resident 3 ' s call light was found on the floor. These failures had the potential for Residents 1 and 3 not to receive necessary assistance when needed, and experienced loss of self-esteem.