Whittier Hills Health Care Ctr

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for one out of three sampled residents (Resident 1) by failing to ensure to implement a care plan for Resident 1, who had a gastrostomy tube (G-tube, a device surgically inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication to individuals unable to eat enough by mouth) and had a behavior of refusing tube feedings. This deficient practice had the potential to result in confusion of resident's care and negatively affect the residents psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly manage and document medications for two of five sampled residents (Resident 1 and Resident 2) by failing to: 1. Document Resident 1's meropenem (intravenous [IV- into the vein] medication used to treat severe bacterial infections) dose on 4/13/2026 and 4/15/2026 at 10 PM. 2. Properly manage Resident 1's medications when three white pills were observed in a medicine cup on the resident's bedside table. 3. Assess Resident 1's ability to safely manage the residents' medications. 4. Document Resident 2's Zosyn (IV medication used to treat severe bacterial infections) dose on 4/15/2026 at 10 PM. This deficient practice placed Resident 1 and Resident 2 at risk for medication errors, including missed, duplicated, or incorrect doses, potential adverse drug reactions, and unsafe medication use.

Inspectors wroteBased on interview and record review, the facility failed to provide and explain the process for obtaining a copy of resident's medical records upon request for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Protected Health Information (information in the medical record that can be used to identify an individual). This deficient practice resulted in violation of Resident 1's and Responsible Party's (RP 1) right to obtain a copy of the resident medical records, in accordance with facility policy.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directives (AD-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) were obtained and accessible in residents medical records for four of four sampled residents (Residents 1, 8, 16, 35, 95 and 201). This deficient practice had the potential for residents' medical treatment provisions to not be carried out, according to the resident's request during emergency situations and/or when a resident was incapacitated (the clinical state in which a patient is unable to participate in a meaningful way in medical decisions).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess functional limitation in range of motion (limited ability to move a joint that interferes with daily functioning or places a resident at risk for injury) for three of four sampled residents (Resident 8, 12, and 49) reviewed for limited range of motion ([ROM] full movement potential of a joint) during their Minimum Data Set ([MDS] a federally mandated resident assessment tool) assessments. Specifically, (1) Resident 8's MDS assessments dated 10/15/2025 and 1/19/2026; (2) Resident 12's MDS assessments dated 10/16/2025 and 1/16/2026; and (3) Resident 49's MDS assessments dated 10/8/2025 and 1/8/2026 were inaccurately completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure daily nursing staffing data was posted. On 2/23/2026, review of the posted Census and Daily Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) and Nursing Staffing Assignment and Sign-In Sheet (NSA, a document to safeguard and ensure adequate, qualified staffing was present to provide resident care) revealed the most recent documents available were date 2/19/2026 and 2/20/2026, indicating the facility failed to post the required daily nursing staffing information for 2/21/2026, 2/22/2026, and 2/23/2026. This deficient practice had the potential to prevent resident's, staff, and visitors from having access to accurate daily staffing data.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling and maintain the food service area in a clean and sanitary manner in accordance with the United States Food and Drug Administration (FDA) Food Code 2022 and the facility's policies and procedures (P&P) titled Storage of Food and Supplies, when: 1. The ground cinnamon spice container lid was partially open on the shelf above the food preparation area by the stove area. 2. The two hot water machine spouts (the part where the hot water flows into the pot or cup) were covered in a white chalky build-up. 3. The side salads and desserts on the lunch trays were not covered during transportation from the metallic delivery food cart to the resident's room.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Services Director (SSD) met the qualifications required for a social worker in a facility with more than 120 residents bed capacity in the facility . The SSD who was hired by the facility on 9/15/2025 as SSD could not provide documented evidence that at least one year of supervised social work experience in a healthcare setting and working directly with individuals prior to the start of employment at the facility. This deficient practice had the potential not to perform the necessary task of experienced SSD which could result improper discharge planning needs, not receiving medically related social services needs of the residents that could negatively impact the well being including the psychosocial well-being of all residents.

Inspectors wroteBased on observation and interview, the facility failed to adhere to infection control practices for 1 of 3 residents (Resident 204) that were reviewed for Enhanced Barrier Precaution (Infection control measures that require all staff to wear Personal Protective Equipment (PPE-gown and gloves during high-contact resident care) in accordance to the facility infection control practice policy when two medical transportation personnel entered Resident 204's room without performing hand hygiene and while wearing gloves from a prior task. Resident 204 had Enhanced Barrier Precautions signage posted due to the presence of a dialysis catheter (medical device that give access into the blood stream to filter out waste products from the blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 23) with indwelling catheter (a flexible, hollow tube inserted into the bladder to continuously drain urine into an external drainage bag) drainage bag was covered to maintain privacy and dignity when the resident's catheter was visible to individuals walking past Resident 23's room. This deficient practice had violated the resident's rights for privacy and the potential to affect the resident's self-esteem and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 35 and Resident 8) received services in the facility with reasonable accommodation of resident needs to ensure that the call light (device used by residents to communicate needs to the nursing staff) was within reach and accessible to the resident, specifically placed on the resident's non-dominant side and out of reach. This deficient practice had the potential to limit Resident 35 and Resident 8's ability to request assistance, safety, and timely access to care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 29 sampled residents (Resident 17) with an admission agreement (legally binding contract between a resident and a nursing facility, detailing the rights, responsibilities, services, and costs for care) in Resident 17's preferred language. This deficient practice had the potential for preventing Resident 17 from being informed of their rights, including contact information for the Ombudsman (trained advocates who investigate complaints, protect rights, and improve quality of life for residents) and the State agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician when two of three sample residents (Resident 8 and 194) with significant change in condition by failing to: 1. Resident 8 had pain and discoloration on her left foot's second toe and pain from her hemorrhoid (swollen veins in the anus and lower rectum [temporary storage chamber for stool before allowing the stool to pass through the anal canal to exit the body]). These failures resulted in the lack of and delay in Resident 8 medical management and coordination which did not address Resident 8 issues regarding her left foot second toe pain and discoloration and her hemorrhoid pain and follow up until the recertification survey team (from 2/23/2026 to 2/26/2026) conducted an investigation on 2/24/2026 into Resident 8's medical care. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the reason for resident's discharge and notice of proposed discharge was completed for one of three sampled residents (Resident 193) reviewed for closed records as indicated in the facility's policy and procedure titled Criteria for Transfer and Discharge, This deficient practice had the potential to result in inappropriate information communicated to the receiving health care institution or provider.

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set (MDS, a standardized assessment and care screening tool) was completed and transmitted to Centers of Medicare and Medicaid Services (CMS) timely for 2 of 3 sampled residents (Resident 32 and Resident 71). This deficient practice failed to provide CMS specific resident information for quality care measure purposes and had the potential to affect the quality of care provided to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to prevent skin injury (a skin damage due to prolonged unrelieved pressure and friction) to ensure the resident's low air loss mattress was set according to the physician's order and within the appropriate weight range for one of two sampled residents (Resident 75). This deficient practice had the potential to place Resident 75 at risk for developing pressure injuries, impaired pressure redistribution, and potential skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion ([ROM] full movement potential of a joint) intervention for two of four sampled residents (Resident 8 and 96) reviewed for ROM limitations. 1. For Resident 8, the facility failed to: -Measure Resident 8's left hand during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 1/19/2026, in accordance with professional standards of practice. -Provide Resident 8 with ROM exercises for both legs from 1/24/2026 to 2/25/2026. -Perform AAROM to Resident 8's left arm in accordance with the physician's orders, dated 1/30/2026. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that two of three sample residents' (Resident 70 and Resident 204) fluid intake was not monitored to restrict fluid intake at 1000 milliliters (mL, unit of weight) per 24 hours while on hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) as ordered by the physician and in accordance with the facility's policy and procedures titled Licensed Nurse Procedures: Fluid Restrictions, 1. Resident 70's total fluid intake was within the fluid restrictions parameters on 2/3/2026, 2/4/2026, 2/17/2026, 2/18/2026, and 2/24/206. 2. Resident 204's total fluid intake was accurately documented and fluid restrictions parameters on 2/13/2026 to 2/25/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the pain level for one of two sampled residents (Resident 203), who verbalized pain during medication pass. This has the potential to result in Resident 203's unmet needs affecting the residents' quality of life.

Inspectors wroteBased on interview and record review the facility failed to follow physician's orders for one of one sampled resident (Resident 4) who was receiving Hydrocodone (medication used to treat severe, chronic pain) as needed for moderate and severe pain. This deficient practice increased the risk of Resident 4 to experience adverse effects (unwanted and dangerous side effect of medications) that could lead to health complications, such as severe respiratory depression [breathing problems], coma, addiction, and severe low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate hospice (interdisciplinary care that is designed to provide palliative care, alleviate the physical, emotional, social, and spiritual discomforts of an individual in the last phases of life due to a terminal disease) services to one of one residents (Resident 96) on hospice care by failing to: 1. Designate a member of the interdisciplinary team fully aware of the role as the hospice coordinator. 2. Ensure Resident 96 received a hospice physician assessment upon admission to hospice on 2/16/2026. 3. Ensure a physician signed the physician's orders, dated 2/16/2026, for Resident 96's admission to hospice. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure therapy equipment was maintained in safe operating condition for one of two adjustable height therapy mats. An adjustable therapy mat in the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) room was observed with a slanted, uneven surface due to a malfunctioning height adjustment mechanism. This failure had the potential to create a safety hazard for residents using the mat for therapy interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system (a communication tool that allows residents to immediately signal for assistance) was maintained in proper functioning for two of four sample residents (Resident 8 and Resident 96) in accordance to the facility's policy and procedure titled Physical Environment: Equipment Maintenance. Resident 8 call light (a button that allows the resident to communicate their need of assistance from the nursing staff) did not light up when pressed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accommodate needs for one of one sampled resident (Resident 1) who had a physician's order for a bariatric bed (specialized bed made specifically to accommodate larger and heavier patients) with bilateral 1/2 bed side rails (a structural support attached to the frame of a bed and intended to prevent a patient from falling) to maintain or achieve independent functioning and well-being. As a result of this deficient practice, Resident 1 was discovered on the floor, lying unconscious on [DATE]. The resident was later pronounced deceased , with the cause of death determined to be natural causes.

Inspectors wroteBased on interview and record review the facility failed to ensure one (1) of 1 sampled resident (Resident 1) was safely provided with her own routine medications from the pharmacy or cubex (automated medication management system to securely store, track, and dispense medications) as ordered by the physician and in accordance with the Policy and Procedure (P&P) titled, Six Rights of Medication Administration. This deficient practice resulted in Resident 1 to miss one dose of albuterol (bronchodilator medicine that relaxes airway muscles to treat and prevent wheezing, shortness of breath, and chest tightness) and to receive one dose of Heparin (an anticoagulant medication that prevents blood from clotting) that belonged to another resident (Resident 3). This had the potential to negatively impact Resident 1's medical conditions resulting in fall with injury, coma, or death. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for two of three sampled residents (Resident 1 and Resident 2) incident on 12/3/2025 by failing to:1. Implement a care plan for Resident 1 after multiple facility staff stated the resident was scared of Resident 2.2. Implement a care plan for Resident 2 after the resident experienced right arm numbness and vision loss. These deficient practices had the potential for a lack of individualized care and to not address Resident 1's well-being and Resident 2's care needs effectively.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain comfortable and safe room temperature levels between 71- and 81-degree Fahrenheit ( F, unit of measurement) in the resident's rooms as for three of five sampled residents (Resident 1, 2, and 3) as indicated by the facility's policy and procedures (P&P) titled Comfortable & Safe Air Temperature Levels This deficient practice resulted in the residents' increased level of discomfort and the potential to result in loss of body heat that could negatively impact the resident's quality of life.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and care plan for two of three sampled residents (Resident 1 and Resident 2) by failing to:1. Follow Physician's Order to limit the resident's sitting to one to two hours at a time with gel cushion on the wheelchair for Resident 1.2. Follow Physician's Order to adjust Alternating Pressure Mattress Replacement System with Low Air Loss (APMRS, mattress that provided pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body were reduced) settings according to Resident 1's height and weight.3. Implement Resident 1's care plan to limit the resident's sitting to one to two hours at a time with gel cushion on the wheelchair and adjust the APMRS settings according to the resident's height and weight.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and secured environment for one of two sampled residents (Resident 1) who has a diagnosis of Dementia (loss of memory, language, problem-solving and other thinking abilities) by mistakenly sending Resident 1 without supervision to a Physicians (Orthopedic- a medical specialty that focuses on the musculoskeletal system, which includes bones, joints, ligaments, tendons, and muscles) appointment outside the facility that was scheduled for another resident (Resident 2) on 11/12/2025. This deficient practice resulted in Resident 1 leaving the facility, unsupervised, to the Orthopedic physician's office, which was eleven (11) miles away from the facility, and had the potential for Resident 1 to be at risk for accidents and/or injuries.

Inspectors wroteBased on interview and record review, the physician failed to accurately document in the physician ' s readmission order and facility failed to record on the Medication Administration Record (MAR) for one of three sampled residents (Resident 1) with gastrointestinal tube (GT- a tube surgically inserted used to deliver medications in fluid form and nutritional formula) to receive medications via GT and not by oral (mouth) when the resident was readmitted to the facility. Resident 1 was receiving medications via GT and the physician ordered the resident to be NPO (nothing per oral) and receive medication per oral. This deficient practice resulted in inaccurate documentation of Resident 1 to receive medications through the wrong route which could result in complication such as aspiration (inhalation of fluid or food into the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two of two sampled residents (Resident 18 and Resident 100) by: 1. Leaving the privacy curtain opened while Resident 100 was being assisted with dressing change. 2. Leaving indwelling catheter drainage bag (a flexible tube used to empty the bladder and collect urine in a drainage bag) uncovered for Resident 18 who required the use of an indwelling catheter. As result of the failure, Resident 100 verbalized being hurt and potentially resulted in emotional distress. These deficient practices had the potential to cause a decline in Resident 18's dignity, self respect, self-esteem, and self-worth.

Inspectors wrote2a. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 3 was readmission to the facility on [DATE] with diagnoses that included of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), chronic obstructive pulmonary disease ( a diseases that blocks airflow and make it hard to breathe) and risk for fall. During a review of Resident 3's History and Physical (H&P), dated 12/24/2024, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 3's care plan for falls, initiated on 12/24/2024, indicated Resident 3 was at risk for falls. The care plan interventions included be sure the call light is within reach and encourage to use it to call for assistance as needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed and submitted in the CMS (Centers for Medicare and Medicaid Services- Long-Term Care) data base within the required time frame for three (3) out of four sampled residents (Residents 85, 98, and 116). This deficient practice had the potential for Residents 85, 98, and 116 to not receive care and services that could negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop a personal centered individualized care plan (a healthcare plan specifically tailored to an individual's unique needs, preferences, and values) that included interventions to prevent elopement (an incident where a resident leaves the facility unsupervised and without staff knowledge) for four out of four sampled residents (Residents 29, 56, 89, and 154), who were at risk for elopement. This deficient practice put Resident 29, 56, 89, and 154 to not receive appropriate care, supervision, treatments, and/or services from staff, compromises the safety and potentially put these residents at risk of elopement and the danger that associated with elopement.

Inspectors wroteBased on interview and record review, the facility failed to provide interventions for safety and supervision for four of four sampled residents (Residents 29, 56, 89, and 154), who were at risk for elopement (an incident where a resident leaves the facility unsupervised and without staff knowledge). These deficient practices put Resident 29, 56, 89, and 154 at risk of elopement and potentially lead to serious injury and irreversible harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of 3 sampled residents (Resident 27, 201, and 202) were provided with safety and comfort while receiving oxygen therapy, in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 27's oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient ' s ears) and nasal cannula did not touch the floor. 2. Ensure Resident 201's humidifier bottle (a water bottle that aids in preventing patients' airways from becoming dry) was not empty for Resident 201. 3. Ensure Resident 202's oxygen tubing did not touch the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to reseal one intramuscular emergency kit (IM e-kit, a collection of supplies of medications that administered into the muscle in an emergency) for one of three sampled IM e-kits and replace the e-kit within 72 hours for Medication room [ROOM NUMBER]. The deficient practice had potential to result in an insufficient number of medications on hand in case of emergency and the potential to result in the inability to identify drug diversion (when a medication is taken for use by someone other than whom it was prescribed or for an indication other than what is prescribed) or misuse.

Inspectors wroteBased on observation and interview, the facility failed to ensure the daily refrigerator temperature logs was completed as required by its policy, compromising its ability to monitor food storage temperatures effectively. This deficiency created a risk of unsafe food storage conditions and potential foodborne illness (caused by consuming contaminated foods or beverages) for residents.

Inspectors wroteBased on interview, and record review, the facility ' s Quality Assessment and Assurance (QAA) committee (a group of facility staff responsible in developing and approving and evaluating established policies and procedures of resident ' s quality of care) failed to develop a policy and procedure related to admission process. Resident 301 was admitted to the facility with diagnosis of Diabetes Mellitus (a condition of having high blood sugar) at General Acute Care Hospital (GACH) 1, which was not monitored for signs and symptoms of high or low blood sugar levels. This failure had a potential for the residents not to receive the care and services for DM and other health concerns that could lead to a decline in the resident's well being.

Inspectors wrote2. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated a readmission to the facility on [DATE] with diagnoses that included of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), chronic obstructive pulmonary disease ( a diseases that blocks airflow and make it hard to breathe). During a review of Resident 3's History and Physical (H&P) dated 12/24/2024, the H&P indicated the resident has the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide sanitary environment for Resident 122 by ensuring an unknown black back brace (a braced used when moving or lifting residents from sitting to standing) was not found in the resident's room on 1/7/2025. This deficient practice had a potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) when used by Resident 122 and other facility's residents. 2. Maintain a safe, functional door with locks that latch which leads to the patio area to maintain a safe environment for all residents and staff. This deficient practice had a potential to put the facility's residents and staffs at risk of injury and harm.

Inspectors wroteBased on interview and record review for one of three sampled residents (Resident 3), the facility failed to ensure Resident 3's Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) was in Resident 3's chart. These deficient practices had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed and submitted in the CMS (Centers for Medicare and Medicaid Services- Long Term Care) data base within the required time frame for one (1) out of four sampled residents (Resident 22). This deficient practice had the potential for Resident 22 to not receive care and services that could negatively affect the provision of necessary care and services .

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility's policy and procedure titled, Physician visits, by failing to ensure Nurse Practitioner (NP) 1 thoroughly reviewed the overall care needed including the hospital record for one of thirty sampled residents (Resident 301) who had a history of type 2 Diabetes Mellitus (DM, a condition of having high blood sugar) that was not monitored for blood sugar levels. The failure had a potential to result in the resident to have uncontrolled blood sugar level that could lead to hospitalization or death.

Inspectors wroteCross reference to F711, F867 Based on interview, and record review, the facility failed to provide care and services to one of - sampled residents (Resident 301) with diagnosis of Diabetes Mellitus (DM, condition that results in too much sugar circulating in the blood) by failing to: 1. Ensure Resident 301 ' s blood sugar was monitored for high or low blood sugar level. 2. Ensure Admitting Registered Nurse (RN) clarified with Resident 301 ' s physician for blood sugar monitoring and treatment. 3. Ensure Nurse Practitioner (NP) 1 thoroughly reviewed Resident 301 ' s General Acute Hospital (GACH) 1 ' s discharge packet when NP 1 took over the care of Resident 301 to clarify Resident 301 ' s history of type 2 Diabetes Mellitus as documented in Resident 301 ' s GACH 1 ' s H&P and justified the need to continue or discontinue blood sugar monitoring and treatment. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a properly place and sized knee immobilizer (a device typically used for injuries that benefit from immobilization but can tolerate brief periods without immobilization to help relief pain and healing) for one (Resident 351) out of three sample residents. As a result of this failure Resident 351 was at risk for injury, discomfort, and complications, such as impaired mobility and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 136) who was identified as at risk for weigh loss, received the prescribed health shake (a nutritional supplement) TID (three times a day) as ordered by the physician. This failure had the potential to result in further weight loss and dehydration (fluid deficit) that could lead to compromised nutritional status and overall, well being.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their smoking policy and procedure for one of three sampled residents (Resident 97) by failing to provide a smoke free environment as indicated in the facilities policy. This deficient practice had the potential to place Resident 97 at risk associated with inhaling secondhand smoke that can potentially lead to diseases such as lung cancer, stroke, heart disease and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of twelve sampled residents who attended the Resident Council meeting on 1/7/2025 was aware of the Ombudsman's (a state agent that advocates for the residents) contact number. This deficient practice had the potential to violate the residents' rights to seek assistance from the Ombudsman or resident advocacy groups should unresolved issues arise from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six (6) of twelve (12) sampled residents who attended the Resident Council meeting on 1/7/2025 was aware of where to find and able to read the facility's previous Annual Recertification Survey with Plan of Correction POC) results. This deficient practice had the potential for the residents and their legal representatives to not be fully informed of the facility's deficient practices and how the facility corrected the deficient practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the faciltys' policy and procedure to prevent developement and worsening of pressure ulcer (skin injury due to prolonged unrelieved pressure or skin friction) by failing to: 1. Resident 90 was not weigh for 90 days to ensure the low air mattress settings (mattress designed to distribute resident's body weight over broad surface to prevent skin breakdown [damage to the skin that can result in redness, tenderness, or an open wound]) was at the correct settings. 2. Resident 78 was not turned and repositioned every two hours as ordered by physician and as indicated in the resident's care plan. Resident 78 was at risk for developing pressure injuries (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatments and services to minimize decline in joint range of motion (ROM, full movement potential of a joint) for three out of seven sampled residents (Residents 125, 86, and 82) who was assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: 1. Ensure Resident 125 received Restorative Nursing Aide (RNA) program (nursing aide program to help residents maintain their function and joint mobility) treatments for active assist range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to both upper extremities (BUE, shoulder, elbow, wrist, fingers) five (5) times a week as ordered by the physician. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident safety in administering oxygen for two (2) of 2 sampled residents (Resident 262 and 261) who were receiving continuous oxygen therapy, in accordance with the facility's policy and procedure by failing to: 1. Ensure the oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor for Resident 262. 2. Ensure the humidifier bottle (a water bottle that aids in preventing patients' airways from becoming dry) was labeled with open date for Resident 262. 3. Ensure the oxygen tubing was labeled with an open date for Resident 262 and 261. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of four of six sample residents (Resident 65,26,310,90) by failing to: 1. Clarify physician orders with overlapping pain scale for Resident 65, which created a potential for duplication of opioid (a class of drugs associated with high potential for abuse) therapy. This failure had the potential to result in opioid overdose and increased risk for adverse consequences such as respiratory depression (trouble breathing) for Resident 65. 2. Accurately account for the use of controlled substances (medications with a high potential for abuse) for Residents 26 and 310) in medication carts (Medication Cart 1A and Medication Cart 2C). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two residents (Resident 90 and 154) were free of unnecessary medications in accordance to the facility's policy and procedure and residents care plan. The facility failed to: 1a. For Resident 90, there was no clinical justification in the resident's medical record for the physician's order that GDR (Gradual Dose Reduction-a process to lower dose of medication to determine if symptoms can be managed at a lower dose) was not attempted due to contraindication for Ambien (a medication to treat insomnia [the inability to fall asleep]) that Resident 90 has been receiving Ambien since 3/23/2023. 1b. Ensure Resident 90 who was receiving Xanax (medication to treat anxiety) and Norco (a medication to treat pain) were monitored for side effects ( undesired effect of medication). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff did not administer expired insulin (a medication used to treat high blood sugar) to at least four out of 11 residents (Resident 43, 65, 103 and 113) whose insulin was found to be expired during the inspection of three of five medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). These failures resulted in residents (Resident 43, 65, 103 and 113) receiving expired insulin doses that could affect the effectiveness of the medication to lower the blood sugar level and the potential to result in serious health complications due to uncontrolled blood sugar levels possibly resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure expired insulin (a medication used to treat high blood sugar) was removed and discarded for 11 residents (Residents 3, 27, 31, 43, 65, 86, 103, 113, 127, 260, and a discharged resident) in three of five inspected medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). 2. Ensure safe, secured, and limited access to prescription medication Keppra ([Generic name- Levetiracetam], medication used to treat seizure condition) for Resident 116. These failures increased the risk that: Residents 3, 27, 31, 43, 65, 86, 103, 113, 127, 260, and a discharged resident could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an plan, implement and evaluate its Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies [a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement]) for identified quality of care deficiencies to pharmacy services. Cross reference to F755, F760, F761 and F757 The facility failed to: 1. Ensure licensed nursing staff administering the medications did not administer expired insulin (a medication used to treat high blood sugar) to at least four out of 11 residents (Resident 43, 65, 103 and 113) whose insulin was found to be expired during the inspection of three of five medication carts (Medication Cart 2A, Medication Cart 2B and Medication Cart 1B). [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to promote dignity and respect for one of three sampled residents (Resident 46). Certified Nursing Assistant (CNA) 12 was observed standing next Resident 46, who was seated in a wheelchair, while assisting the resident to eat lunch. This deficient practice violated the resident's rights to maintain and enhanced their self-esteem, self-worth, and the right to be treated with dignity and respect.

Inspectors wroteBased on observation, interviews, and record review the facility failed to notify the resident's primary physician for one of one sampled resident (Resident 87) who refused glucose monitoring (a test that measures the amount of sugar in a resident's blood). These failures have the potential to result in the decline of Resident 87's medical status which included hypoglycemia (low blood sugar; can cause weakness, confusion, and coma), hyperglycemia (high blood sugar; can lead to blindness and heart problems) and possible hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to take reasonable steps to protect three of eight sampled resident's (Resident 9, 59, 115) personal property from loss or theft in accordance with the facility's policy and procedure titled, Personal Effects, Inventory of, for by failing to provide accurate and updated inventory of personal belongings. This deficient practice had the potential to result in the loss or theft of resident's belongings that has importance in their lives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 46) was free from physical restraints (the use of a device that restrict freedom of movement of all or part of a person's body), by failing to ensure: 1. Resident 46 who had impaired cognition (ability to think and reason) was able to release the self-release belt (a belt that is placed around the residents waist while seated in the wheelchair which could restrict the resident's freedom to move or mobilize) without assistance. 2. A less a less restrictive measure was used to prevent Resident 46 from fall. 3. Identify the Self Release Belt as a restraint since Resident 46 could not release the self-release belt without assistance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate one of three sampled residents (Resident 125) using the Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals with mental illness or disability are not inappropriately placed in nursing homes for long term care) level I to identify suspected mental illness, intellectual/developmental disability, or related condition. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed develop a comprehensive, resident specific plan of care for two of two sampled residents (Resident 24 and Resident 46) who were placed on self-release/self-administer seat belt (a belt placed on a resident while seating on a wheelchair) due to resident making unassisted attempts of getting out of the wheelchair. This deficient practice had the potential to resulted in facility staff not monitoring the specific needs and care regarding the use of self-release belts for Resident 24 and Resident 46.

Inspectors wroteBased on interview and record review, the facility failed to review, revised and update the care plan for one of eight sampled residents (Resident 25) who was discharged from hospice services (care services specialized for end-of-life care and needs) and continued to have a care plan regarding hospice care. These deficient practices placed Resident 25 at risk for not receiving necessary services and treatment which could impact quality of care and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow care plan to ensure safe medication administration for one of five residents (Resident 70) with diagnosis of dysphagia (a medical term for swallowing difficulty). This failure resulted in Resident 70 not receiving resident centered care and had the potential for the resident to choke and aspirate (a condition in which food, liquid or medicine go down the wrong airway while swallowing) during medication administration.

Inspectors wroteBased on interview and record review the facility failed to do a pain reassessment after one hour of administering Norco (prescribed medication to treat moderate to severe pain) and Tylenol (medication to treat mild to moderate pain) for one of one sampled resident (Resident 56). This failure had the potential to result in not identifying the effectiveness of pain medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve lunch meal service at 12PM as indicated in the facility's policy and procedure titled, Mealtime Service to three of six sampled residents (Residents 25, 59, and 124). These deficient practices resulted in three residents not receiving meals at regularly scheduled time, in which the resident's complained of hunger. In addition, the residents who are receiving medications that lowers the blood sugar level could cause dangerously low blood sugar levels or not receive medications with meals as prescribed by the physician, which could compromise the resident's wellbeing.

Inspectors wroteBased on observation, interviews, and record review the facility failed to: 1. Separate dented cans on the shelf in the dry food storage area. 2. Label used or opened food items with an expiration date and remove expired food items in the resident refrigerator, kitchen refrigerator, kitchen freezer and dry goods storage. 3. Ensure staff used gloves or utensils when handling and preparing food. 4. Ensure the top exterior of the ice machine was clean. These failures have the potential to expose the residents to a food borne illness (illness caused by eating dirty food; symptoms include: nausea, vomiting, diarrhea).

Inspectors wroteBased on interviews and record reviews, the facility failed to implement a physical therapy (PT, a type of treatment to help manage movement and reduce pain in people) order for one of one sampled resident (Resident 6). This failure had the potential to result in a decline of Resident 6's mobility, activities of daily living, and overall physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure titled Physician Orders for Life Sustaining Treatment (POLST, a physician order form that complements an advance directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation in physician orders) for two (2) of three (3) sample residents (Resident 1 and 3). 1. Resident 1 did not have a POLST during the entire stay at the facility from 6/14/2023 to 10/24/2023. 2. Resident 3 did not have a POLST readily accessible in the resident's records. This deficient practice had the potential to result in a delay in treatment and life sustaining emergency during an emergency situation.

Inspectors wroteBased on observation, interview and record review the facility failed to implement the facility ' s policy on Reporting Alleged Violations of Abuse, Neglect, Exploitation Policy and Procedure duringthe provision of care and services of one of three sampled licensed nurses for 151 residents (facility census) residing in the facility, when the facility received an allegation of abuse from the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) on 10/20/2023. The facility failed to: 1. Support an environment in which staff and others freely and without hesitation report situations which may be or are consistent with abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify hazards and maintain a safe environment for one of two sampled residents (Resident 1) with diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain) by failing to: 1. Ensure a comprehensive, resident-centered care plan was developed and implemented for Resident 1, who had history of active seizures and was on seizure precautions that included the necessary precautions Resident 1 required, to be free from injury due to seizure activity. Resident 1 ' s care plans for seizure precautions did not include padded bed side rails. Resident 1 ' s bedside rails was not up as indicated in the resident ' s care plan for Risk for Falls. 2. Ensure resident equipment was maintained in good working order to prevent potential for accidents and injury. [...]