Whittier Pacific Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for three of 25 sampled residents (Resident 90, 91, and 100) by failing to: a. Develop and implement a care plan for Resident 90's Gastro-jejunal (GJ tube, two main ports labeled G leading to the stomach for draining air or fluid and J bypassed the stomach to deliver nutrition directly into the small intestine, used for feeding and medicine) tube and implement a care plan for Resident 90's GJ tube formula feeding. b. Develop and implement a care plan for Resident 100's gastrostomy (G-tube, a small flexible feeding tube inserted through the skin directly into the stomach to provide nutrition, fluids, and medication) tube formula feeding. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and implement range of motion ([ROM] full movement potential of a joint) interventions for one of five sampled residents (Resident 6) reviewed for ROM limitations by failing to: 1. Complete Resident 6's Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in each joint of both arms and legs) (Occupational Therapy [(OT) profession aimed to increase or maintain a person's capability of participating in everyday life activities]) - Upper Extremities (arms) to assess ROM in both arms after readmission on [DATE] and 3/7/2026 in accordance with the facility's policy and procedure (P&P) titled, Screening, dated 8/10/2023. 2. Provide Resident 6 with ROM exercises to both arms from 11/24/2025 to 2/15/2026. 3. Provide Resident 6 with ROM exercises to both legs from 11/24/2025 to 3/3/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to procure, store, prepare, and serve food under sanitary conditions in accordance with the facility's policy and procedures titled Sanitation and Infection Control and Refrigerator/Freezer Storage by failing to: a. Discard six bags of turkey slices, three bags of ham slices, and one bag of pork patties that were expired from the walk-in freezer. Properly label the used by date for six bags of turkey slices, three bags of ham slices, and label the open and used by date for one bag of pork patties. b. Perform proper hand hygiene or changing gloves between handling soiled and clean items when the Dietary Aid (DA) was taking dirty equipment to the sink and picking up clean metal containers without changing gloves or washing hands. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the complete and accurate medical records in accordance with the facility's policy and procedure (P&P) titled, Charting and Documentation, for four of four sampled residents (Resident 2 and Resident 7, 112, and 114) as evidenced by: 1. For Resident 112, Licensed Vocational Nurse 1 (LVN 1) documented the administration two of Resident 112's prescribed supplements that were omitted during medication pass. 2. For Resident 114, the facility failed to document Resident 114's vomiting on 3/11/2026, including the interventions taken after vomiting. These failures had the potential to prevent Resident 112 from receiving the intended therapeutic benefit of her supplements and had the potential to worsen her health status and condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for three of five residents (Resident 71, 79 and 88) reviewed for infection control by failing to: 1. Ensure Certified Nursing Assistant (CNA) 2 and CNA 3 wore an isolation gown when assisting with feeding for two of two sampled residents (Residents 79 and 71) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]). 2. Clean Resident 88's hearing aid after falling on the floor and prior to placing it into Resident 88's right ear. These deficient practices had the potential to introduce bacteria (organisms that can cause disease) into Resident 88's ear, which could result in infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary, environment when the exterior trash storage area in a clean and sanitary manner when the trash bin was overflowing with garbage, with the lid unable to fully close, and two empty boxes were left on the ground near the bin. This deficient practice had the potential to attract pests for the environment for residents, staff and the public that could result in widespread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the primary physician and responsible party regarding a significant change of condition for one of five sampled residents (Resident 40) reviewed for limited range of motion ([ROM] full movement potential of a joint) when Resident 140's left knee ROM declined from normal joint movement on 6/30/2025 to moderate ROM limitations (25-50 percent [%] loss of motion in the joint) on 3/3/2026. This failure prevented Resident 40's physician from being informed for additional interventions to prevent further ROM decline in Resident 40's left knee. This failure also prevented Resident 40's responsible party from being informed of Resident 40's change of condition in the left knee.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4) was free of unnecessary medications when: 1. Registered Nurse (RN) 4 renewed Resident 4's discontinued order for Lorazepam (Ativan- a medication that reduces anxiety) without authorization from Medical Doctor (MD) 1 or Nurse Practitioner (NP) 1. 2. Licensed Nurses (LNs) did not document nonpharmacological interventions (NPI- non-medication approaches to address behavioral symptoms such as anxiety, insomnia, or agitation) prior to administering Resident 4's PRN Lorazepam. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly wound assessments were completed and documented for one of three sampled residents (Resident 112) who had a post surgical wound. This failure resulted in the facility's inability to monitor the wound's healing progress, identify changes in condition, and ensure timely intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided in accordance with professional standards of practice for enteral nutrition for one of four sampled residents (Resident 90) by failing to: 1. Complete a comprehensive assessment upon readmission to the facility and identify Resident 90's new Gastro-jejunal (GJ tube, two main ports labeled G leading to the stomach for draining air or fluid and J bypassed the stomach to deliver nutrition directly into the small intestine, used for feeding and medicine) tube. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 46) received oxygen therapy at two liter per minute (L/mi) continuously according to the physician's order. This deficient practice had resulted in Resident 46 receiving less oxygen than prescribed and had the potential to cause respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services for one of three residents sampled for medication administration (Resident 112) by failing to reorder Resident 112's routine Olmesartan Medoxomil (a blood pressure medication), Isosorbide Dinitrate (another blood pressure medication), and Raloxifene Hydrocholoride (a medication used to treat osteoporosis- weak and brittle bones due to lack of calcium and Vitamin D) three (3) days prior to the last dosage being administered per the facility's policy and procedure (P&P). This deficient practice resulted in Resident 112 missing her medications as scheduled and placed Resident 112 at risk of complications related to hypertension (HTN- high blood pressure) and osteoporosis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the medication error rate was less than five percent (%). During medication pass four (4) medication errors out of a total of 30 opportunities contributed to 13.33% medication error rate affecting one of three residents observed for medication administration (Resident 112). 1. Failure to check Resident 112's pulse rate prior to administering Metoprolol Succinate (a blood pressure medication that lowers both blood pressure and pulse rate) with parameters to hold the medication for a pulse rate less than 60 beats per minute (bpm). 2. Failure to administer Olmesartan Medoxomil (another blood pressure medication) due to failing to refill Resident 112's medication after it ran out. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of two medication storage areas (MSA 1) by failing to discard an opened vial of Aplisol (Tuberculin Purified Protein Derivative, PPD) within 30 days as required by the manufacturer's instructions. The Aplisol vial, opened on [DATE], remained stored in the facility's medication refrigerator until [DATE], exceeding the 30 day discard date by 11 days. This failure had the potential to result in inaccurate test results, misuse of expired medication, and compromised resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was at risk for skin breakdown, was provided standards of quality care and services while using a low air loss mattress (LALM - a specialized therapeutic support surface that uses a constant flow of air through micro-vents to reduce skin moisture and heat, preventing and treating Stage I-IV pressure ulcers) As a result, Resident 1 had an alteration of skin and a reopening of the right trochanter (thigh bone) fragile scar tissue. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included sepsis, contracture of right and left knee, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services specific to the needs required for one of two sampled residents (Resident 1) who had a nephrostomy tubes (a thin, flexible tube that is inserted through the skin of the lower back directly into the kidney that is used to drain urine when the normal flow through the ureter to the bladder is blocked or impaired) by failing to: 1. Initiate and revise Resident 1's care plan to indicate actual and preventative measures for nephrostomy tube dislodgement. 2. Conduct an Interdisciplinary Team (IDT a group of professionals from different disciplines who work together to create and update a resident's individualized care plan) meeting to assess the root causes for Resident 1's nephrostomy tube dislodgement. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that accurate staffing information was posted in a visible and prominent place on a daily basis, as required by the facility's policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers. This failure had the potential to prevent residents and visitors from being informed of the facility's accurate daily staffing levels.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) who was assessed with contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) received treatment and care services in accordance with the resident's care plan for by failing to: 1. Ensure facility staff implemented Resident 1's care plan developed on 7/21/25 to immobilize the resident's right arm, to hold Range of Motion (ROM - a type of exercise designed to maintain and improve the flexibility and movement of joints) exercises as evidence by documentation survey report indicating exercises to the right arm was performed on 7/21/25, 7/22/25.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for one of one sampled resident (Resident 4), when Resident 4 ' s indwelling Foley catheter (a thin, flexible tube inserted into the bladder to drain urine continuously) urinary drainage bag (urine drainage bag to collect urine) was observed without a urinary drainage bag cover. This deficient practice had the potential to violate resident rights to maintain and enhance self-esteem, self-worth, and the right to be treated with dignity and respect.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse staffing information that was indicated on the Daily Skilled Nursing Facility (SNF) Staffing for certified nurse assistants (CNA) was accurate. This deficient practice had the potential to misinform residents and visitors of the number of CNA's providing care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four outdoor refuse containers (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) was closed with a tight-fitting lid and kept covered. This failure had the potential to attract insects and harbor pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors.

Inspectors wrote3. During a review of Resident 72 ' s admission Record (Face Sheet), indicated the facility admitted Resident 72 on readmitted on [DATE] with diagnoses that included diabetes mellitus (DM: long-term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), epilepsy (a brain disorder that can cause people to suddenly become unconscious and have violent, uncontrolled movements of the body) and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). During a review of Resident 72 ' s History and Physical (H&P), dated 9/12/2024 indicated, Resident 72 does not have the mental capacity to make medical decisions. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient staffing were provided to perform RNA (Restorative Nursing Assistant) assisted services and exercises as ordered by the physician to the residents in the facility that had limited range of motion (ROM). Two of Two RNA's (RNA 1 and 2) assigned to perform RNA services and exercises reported they were reassigned to perform Certified Nursing Assistant (CNA) duties when the facility had no sufficient CNA to attend to residents in the facility. This deficient practice had the potential to result in a decline in the resident's quality of care and further decline in mobility and ROM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility ' s error rate was less than five percent (5%). During a medication pass observation License Vocational Nurse (LVN )1 did not flush in between each medication administration via gastrostomy tube [GT- a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow] to one of three sampled residents (Resident 86) resulting in 33.3% medication error rate for nine medications out of 27 opportunities. These deficient practices had the potential to result in inconsistent medication administration, risks of physical and chemical incompatibilities between the medications, that could alter drug therapeutic effectiveness, and stomach irritation.

Inspectors wroteBased on observation, interview, and record review, the facility ' s Quality Assessment and Assurance (QAA) committee failed to maintain an effective system to identify, monitor and evaluate implementation of a plan of correction for the deficient practice previously cited on 8/1/2024 related to insufficient Restorative Nursing Assistant (RNA, a certified nurse assistant [CNA] with specialized training in rehabilitation skills who assists the restorative team with supervised and delegated restorative programs) and CNA and residents not RNA services o provide exercises and devices as ordered by the physician to prevent decline in the mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed implement the facility's policy and procedure on infection control to prevent spread of infection for five of five sampled residents ( Resident 62, 67, 92, 78 and 77) by failing to: 1. For Resident 62, the resident's Suprapubic Catheter (a medical device that drains urine from the bladder directly through the abdominal wall) attached to a drainage bag that was found of the floor. 2. For Resident 67 and Resident 92, Certified Nursing Assistant (CNA) 1 did not perform hand hygiene before and after providing care between the residents. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 16 and 39) was offered to formulate and received information related to Advance Directive (a legal document indicating a resident's preference on end-of-life treatment decisions) information during their initial admission and subsequent re-admission to the facility. This failure had the potential to result in Resident 16 and 39 not having their wishes met regarding end-of-life treatment decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Discharge Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted timely and within 30 days, to the Centers for Medicare and Medicaid Services (CMS) system for one of 19 sampled residents (Resident 87) MDS Assessments. This deficient practice had the potential to affect the quality-of-care monitoring system to ensure safe, efficient, resident centered care in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice in nursing care for one of two sampled residents (Resident 86) by failing to: 1. Check for gastric residual volume (refers to the volume of fluid remaining in the stomach) using a syringe to suction out the stomach fluids via Gastrostomy Tube (G Tube-a tube surgically inserted into your stomach through your abdomen) before medication administration. 2. Flush (rinse) the G-tube with water in-between each medication administration. This failure had the potential to cause complications, including aspiration (inhalation of foreign materials) and pneumonia (a lung infection), and clogged GTube needing a surgical replacement thta could negatively impact the resident's care and health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to initiate routine Bowel and Bladder training programs to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) for one of one sampled resident (Resident 198) who was assessed at being high risk for fall. Resident 198 was observed walking out of his room and falling on top of plastic Wet Floor sign placed in front of his room door when attempting to use the restroom unassisted by facility staff. This deficient practice had the potential to result in unmet resident ' s needs, which can result in Resident 198 to sustain serious injuries from a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and safety measures to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) for one of one sampled residents (Resident 198) with high risk for fall. Resident 198 was observed walking out of his room and falling on top of plastic Wet Floor sign placed in front of his room door. This deficient practice had the potential for Resident 198 to sustain serious injuries from the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provider appropriate assessments, treatments, and services for one of one sampled residents (Resident 82) who was incontinent (involuntary loss of urine) of bladder and had an indwelling foley catheter (a thin, flexible tube inserted into the bladder to drain urine and left in place for a set amount of time) for wound care management. Resident 82's foley catheter was not strapped properly to her leg to prevent dislodgement (removal) and had sediment (particles free floating in urine) in the urine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate alternative interventions before installation of bilateral upper half side rails (metal or plastic bars attached to the side of the bed) for one of one sampled resident (Resident 298). This failure had the potential for Resident 298 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the side rails) and physical injuries

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled Licensed Vocational Nurses (LVN 2) and one out of three sampled Certified Nursing Assistants (CNA 3) in the facility completed their annual competency assessment and evaluation (a process that assess and evaluates an employees skills, knowledge and performance) for the appropriate job category when providing quality care. As a result of this deficient practice placed the residents at risk for not receiving competent/quality of care services, treatments, and risk for infection from daily care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide required specialized rehabilitation services (services that included but is not limited to physical therapy [provide exercises to help injured or ill people improve movement and manage pain] and occupational therapy [helps people to have physical, sensory, or cognitive problems] and promoting independence for individuals with complex rehabilitation needs in accordance with facility policy and professional standards of care for one of four sampled residents (Residents 14). For Resident 14 was not assessed and addressed for potential joint mobility concerns annually and quarterly since 2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement (a provide agreement that allows individual parties to resolve disputes rather than in a lawsuit) to one of three sampled residents (Resident 198) in a form and manner that his responsible party understands. Resident 198 ' s responsible party reported not understanding the arbitration agreement and the rights to make informed decisions and choices about important aspects of Resident 198 ' s health, safety, and welfare. This failure resulted in the resident's responsible party not to make an informed decision about the resident's care to ensure the resident received care according to his rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident ' s call light in operating condition for three of four residents sampled (Resident 5, 48 and 62). This deficient practice had the potential for unmet resident ' s needs and calls for assistance that, may cause negative outcomes such as accidents/injury and/or anxiety (fear of the unknow) and depression (a severe feeling of hopelessness and sadness).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's bedroom measured at least 80 square feet (sq. ft.-a unit of measurement) per resident in multiple resident bedrooms for 11 out of 39 resident's rooms. Rooms 5, 6, 8, 9, 11, 12, 14, 15, 16, 17, and 18 measured less than 80 sq. ft. per resident. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to accommodate the needs of four of five sampled residents (Residents 1, 3, 4 and 5) by failing to answer the call light (a device used by patients to call for assistance from staff) in a timely manner. This deficient practice had the potential to increase the risk for falls, delay medical attention for urgent needs, increase residents discomfort, frustration, and potentially contribute to residents' harms or irrversalble injuries.

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility ' s policy and procedure for influenza immunization for one of five sampled residents (Resident 1) by failing to: 1. Offer the influenza vaccine (a vaccine to protect against the influenza virus, or flu. 2. Provide education regarding the benefits and potential side effects of the medication. 3. Indicate Resident 1 ' s refusal to receive the influenza vaccine with the resident ' s name and signature. This deficient practice increases the risk of Resident 1 ' s potential to be infected with the influenza virus that could lead to severe illness, hospitalization, or death.

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility ' s Covid-19 policy and procedure for one of five sampled residents (Resident 1) by failing to: 1. Offer the Covid-19 2024/2025 vaccine (a vaccine intended to provide acquired immunity against the coronavirus disease) to Resident 1. 2. Provide Education to Resident 1 about the benefits of receiving the Covid-19 vaccine and risks of refusal. 3. Document Resident 1 ' s refusal of the Covid-19 vaccine with the resident ' s name and signature This deficient practice put Resident 1 at risk to infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that facility staff implement the facility ' s policies and procedures on Abuse, Neglect , Exploitation and Misappropriation Prevention Program and Abuse, Neglect, Exploitation and Misappropriation -Reporting and Investigating during the provision of care and services for one of two sampled residents (Residents 1). The facility failed to: Identify and investigate all possible incidents of abuse when Resident 1 reported she did not want Certified Nursing Assistant (CNA)1 providing her pericare (the practice of washing the genital and anal areas of the body) on 10/27/2024. Investigate and Report all alleged possible incidents of abuse immediately to the Administrator, state licensing agency within two hours, in accordance with the federal regulations. [...]

Inspectors wroteBased on interview and record review the facility failed to document resident ' s belongings and prevent personal items from being lost for one of four sampled resident (Resident 1) by failing to document the resident ' s rosary as indicated in the facilities policy and procedure (P&P). This deficient practice resulted in Resident 1 ' s rosary being lost.

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services for one of four sampled resident (Resident 1) by failing to follow up on an x-ray (invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media) recommended by the dentist for Resident 1 ' s bottom left aching tooth to further evaluate and treatment as indicated in the facility ' s policy and procedure (P&P). This deficient practice had the potential for delay in care and services lead to the potential for Resident 1 to suffer pain from the aching tooth and loss of tooth.

Inspectors wroteBased an interview, and record review the facility failed to follow infection prevention and control practices and implement interventions to prevent and control the spread of infections in the facility by failing to transport and store dirty linen in accordance with the facility ' s policy and procedure for six of six sampled residents (Resident 3, 4, 5, 6, 7, and 8). This deficient practice had the potential to result in an increased spread of infection in the facility leading to serious illness and death.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician after one of three sample residents (Resident 1) fell from a shower chair (a plastic chair with wheels used for resident to shower) on 8/1/2024. This deficient practice had the potential for the resident not to receive the necessary care, monitoring and supervision need to prevent recurrent fall. In addition this had the potential for the resident not to receive or receive delayed interventions after a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for two of two sampled residents: 1. For Resident 1 with history of falls by ensuring interventions are deveopled to prevent recurrent fall. Resident 1 had a fall on 8/1/24 and there was no documented evidence the incident was documented Resident 1's clinical record. These failures had the potential to result in Residnet 1 to have a recurrent fall due to the lack knowledge of the staffs to know the interventions needed to prevent Resident 1 from falsl that could result in injuries and death. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to promote wound healing by failing to follow the facility ' s policies and procedures on Prevention of Pressure Injuries, and Wound Care, when providing incontinent care to residents with a pressure ulcers in the Sacrococcyx (the fused sacrum and coccyx, or tailbone) and Coccyx (the small bone at the bottom of the spine) area for two of four sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to place the residents at risk for poor wound healing and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident ( Resident 1) with a history of fall and had a recurrent fall on 8/1/24 was investigated for cause of fall and implemented interventions that addresses resident ' s risk factors for falls to prevent recurrent fall. This failure had the potential for Resident 1 to have a recurrent fall and have a significant change in condition that is not monitored and result in delayed or not receive the necessary care and interventions to prevent a recurrent fall that could lead to injury and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to the residents by ensuring the Restorative Nursing Assistant (RNA-a certified nursing assistant (CNA) with specialized training in rehabilitation skills who assists the restorative team with supervised and delegated restorative programs) was not assigned to perform Certified Nursing Assistant duties ( to perform Activities of Daily Living- such as bathing, feeding and repositioning residents) instead of performing range of motion (ROM) exercises (Movement of joint exercise) to 19 to 19 of residents on RNA program, including Resident 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posting was updated and placed in a visible and prominent place daily that indicated the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors to. On 7/31/24 the nursing posting was not observed for residents, responsible party to review if the facility had adequate staffing for the day. This deficiency had the potential to result in the lack of the staff providing care to the facility without the responsible party and resident ' s awareness and result in the resident ' s not receiving quality of care.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate clinical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 6). Restorative Nurse Assistant (RNA-a Certified Nursing Assitant with specialised training in providing range of motion exercises) 1 admitted that she willfully documented in Survey Report for RNA tasks for Resident 6 ' s that RNA exercises were provided to Resident 6 on 7/10/24 and 7/22/24 even though she was not at the facility, off duty and did not provide the exercises to Resident 6. The deficient practice had the potential for the resident and other residents not to receive necessary RNA assisted exercisied to improve or maintain range of motion of the extremities and the body that results in the deterioration of rehabilitative condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified for one of two sampled residents (Resident 1), who had a history of self-decannulation (process to remove tracheostomy [procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck] tube). This deficient practice had the potential for residents to not receive appropriate care, treatment and/or services. As a result, Resident 1 self-decannulated three times while a resident at the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan consistent with professional standards of practice for a resident with trachoestomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), that included specific behaviors and interventions to monitor tracheostomy self-decannulation (process to remove tracheostomy tube) for one of two sampled residents (Resident 1) who had a history of self-decannulation. This deficient practice had the potential for residents to not receive appropriate care, treatment and/or services. Resident 1 had self-decannulated three times while a resident at the facility on 6/9/2024 at 10:15 AM, 6/23/2024 at 3:30 AM and 11:30 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to one of 3 residents (Resident 3) with Gastrostomy tube (G-tube a soft plastic tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) by ensuring an abdominal binder (fitted elastic material that goes around abdomen to support muscle and or keep bandage in place) was in use as ordred by the physician order to prevent from pulling out or dislodge ( accidental removal). This deficient practice had the potential to result in G-tube dislodgement that can lead to complications including trauma, infection of G-tube site and delayed nutritional feeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the prescribing physician document the rationale for extending the use of two PRN (as needed-not given on a regular schedule) psychotropic medications for two out of fourteen sampled residents as indicated in the facility ' s policy and procedure titled Psychotropic Medication use. These deficient practices increased the risk of Residents 1 and 2 to experience adverse effects of the psychotropic medications including, but not limited to, dizziness, drowsiness, leading to an overall negative impact to their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and investigate the allegations made by a resident ' s representative (RP 1) for one of three sampled residents (Resident 1) and submit a written report of such findings to the administrator and RP 1, in accordance with the facility ' s policies and procedures. RP 1 complained that Resident 1 ' s specialized wheelchair had been missing, but the facility did not make prompt efforts to resolve the problem and provide a written response to RP 1 regarding the resolution of the grievance. This deficient practice had resulted to Resident 1 ' s rights to have grievances resolved, in accordance with the regulations and the facility ' s policy and procedure.

Inspectors wroteBased on interview and record review, the facility failed to update and revise the care plan for two of three sampled residents (Resident 1 and Resident 3) by failing to: 1. For Resident 1, revise and update the care plan after the resident tested positive for Carbapenem-resistant Acinetobacter baumannii (CRAB, a type of bacteria commonly found in the environment, especially in soil and water) that requires isolation (a condition where a resident has to be isolated to prevent the spread of the infection). 2. For Resident 3, revise and update the activity care plan after the facility identified the type of music the resident enjoys listening. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of two sample residents (Resident 4) was free from accident hazards to prevent injury during transfer from bed to the shower gurney (also called a shower bed, used to transport an immobile person to and from a bathing area) using the mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond manual support), on 2/16/2024 by failing to: 1. Ensure Resident 4's bed siderails were down and not left raised (elevated at higher position) while the resident was being transferred with the mechanical lift from the bed to the shower gurney. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for the resident to clear the area of any obstruction during a transfer with the use of mechanical lift for two of three sampled residents (Resident 6 and Resident 7). These deficient practices had the potential to place the residents at risk for injuries and fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside for one (1) of one (1) sampled residents (Resident 5) in accordance with the facility policy and procedure. This deficient practice had the potential for an inaccurate accounting and administration of medications for Resident 5 as indicated on the physician's order. It also had the potential for other residents to access the unattended medication and cause possible harm if ingested.

Inspectors wroteBased on interview and record review, the facility failed to provide Physical Therapy (PT, medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) per physician (MD) order for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 to experience a decline in mobility and range of motion (ROM), and tightening and weakness to the resident's muscles.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat one of two sampled residents (Resident 1) with respect and dignity preventing staff from making inappropriate comments regarding care to Resident 1. This deficient practice had the potential to affect Resident 1's self esteem and to feel embarrassed that could lead to a psychosocial (mental and emotional well-being) decline, resident ' s individuality and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide safe, accident and hazard free environment for five of 24 residents (Residents 37, 87, 92, 149, 150) with impaired cognition (mental action or process of acquiring knowledge and understanding) who were observed with improperly fitting mattresses and bed frames with gaps between the mattresses and footboard. This deficient practice had the potential to negatively affect the safety of Residents 37, 87, 92, 149 and 150, that placed the residents at risk for accidents or entrapment (trapped or entangled in the spaces in or about the bed rail, mattress, or hospital bed frame) and trap the resident's head, body, arms and legs between the rails and mattress which could result in injuries and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system-wide method of accountability for controlled medications (medication with a high risk of abuse or theft) and maintain a system to ensure accountability of controlled medications to track compliance with its policy on Controlled Substances. The change of shift narcotics reconciliation records titled Narcotic Key Control, the facility uses for the controlled medication reconciliation on (a process of counting all the controlled medication in the medication cart between the nurse leaving and the nurse coming on duty to determine if there are any discrepancies) were not signed by two nurses during shift change between for one of two medication carts (Station 1 Cart1) inspected. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store and prepare food under sanitary conditions in accordance with the facility's policy and procedure by failing to: a. Ensure open food items stored in the refrigerators were labeled and dated. b. Discard the expired food items and were not stored in the dry goods storage area. c. Failed to complete QUAT Sanitizer (QUATSL-agent used to kill germs and disease causing organism) Log for January 2024 and Dish Machine Temperature Log (DMTL) for January 2024. The deficient practice had the potential to result in the growth of bacteria and transmission of foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever which could lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to have measures to prevent the growth of Legionella (bacteria found in water, including groundwater, that causes severe pneumonia [severe infection in the lungs] that is transmitted through breathing in Legionella-contaminated, aerosolized [the form of a fine spray] water, soil and water borne pathogens (an organism that can cause disease) in the buildings water system. This deficient practice had the potential to result in widespread infection in the facility and could negatively impact all residents and staffs, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the bed frames, mattresses and bedrails were checked for compatibility and size prior to use and the staff, routinely inspects all beds and related equipment to identify risks and problems including potential entrapment (trapped or entangled in the spaces in or about the bed rail, mattress or hospital bed frame) risk for five of 24 residents (Residents 37, 87, 92, 149, 150) who were observed with 5 to 6 inches gaps between the mattress and footboard. This deficient practice had Residents 37, 87, 92, 149 and 150 to have their arms, legs, foot, legs and head to entrap between the bed mattress and foot board and result in injury and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 26 and 4), were treated with respect and dignity as indicated in the facility's policy and procedure, by failing to: 1. Provide privacy and honor Resident 26's preference to keep gown and incontinent brief on before going to the shower room. This failure resulted in Resident 26's emotional distress manifested by crying, reported feeling embarrassed and frustrated which could potentially result in the resident not able to enhance her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. 2. Cover Resident 4's indwelling catheter bag (drainage bag that collects urine from the tube inserted in the bladder into the bag outside of the body). [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a string attached to the call light in the bathroom located in Room A that could be reached and used to call for assistance when needed by one of one sampled resident (Residents 247). This deficient practice had the potential to result in a delay in provision of care and assistance in the bathroom or in an event of emergency that could and lead to falls, accidents, and injuries.

Inspectors wroteBased on interview and record review, the facility failed to maintain a current copy of the resident's advance directive (legal document that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) in the resident's medical record for one of one sampled residents (Resident 77). This deficient practice had the potential for Resident 77 to not have their wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment by ensuring the three of 3 clothes dryer's lint trap (a part of the dryer that collects lint) in the laundry room were removed and cleaned after each dryer cycle and/or cleaned on the scheduled times. This deficient practice had the potential to cause fire in the facility and endanger the lives of the residents, staffs, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident one of three (3) sample residents (Resident 24) was provided a communication device (a tool used to communicate with someone) that was readily available in a language that the resident could understand, and the resident's primary language. This deficient practice may result in the resident not to effectively communicate her care needs with the staffs, which could lead to a delay in receiving appropriate care/treatment when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Residents 74) with low air loss (LAL) mattresses (a mattress used to provide alternating pressure to the bony part of the body) was set according to the residents' weights to ensure effective prevention and/or worsening of pressure ulcers (areas of damaged skin caused by staying in one position for too long) in accordance to the manual for Med-Aire Essential 8-inch Alternating Pressure Mattress Replacement System with Low Air Loss. Resident 74, who weighed 165 pounds (lbs.), was observed with the LAL mattress setting at the highest setting for a person weighing 350 lbs. This deficient practice placed Resident 74 at risk for development of new pressure ulcer, delayed and worsening of the pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 4), who was not assessed for cognitive status (ability to think and process information) , vital signs (measurrement of the blood pressure, heart rate, breathing rate and body temperature), and the dialysis access site (sugically inserted catheter into the body [usually arms, chest groin] and connects to the dialysis machine that removes excess fluids and toxins in the blood) after returning to the facility from the dialysis center (treatment for people whose kidneys are failing). This deficient practice had the potential to delay the detection of complications including infections and bleeding for Resident 4.

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of five Nursing Assistants hired by the facility had current and active Certified Nursing Assistant (CNA) certifications to demonstrate competency skill sets and techniques necessary to care for and identify the need of the residents. CNA 1 continued to be assigned to work at the facility for three shifts (48 days after her CNA certificate expired) and CNA 2 continued to be assigned to work at the facility for 33 shifts (41 days after her CNA certification expired). This failure had a potential to result in facility's residents not to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for eleven out of forty-three resident rooms (Rooms 5, 6, 8, 9, 11, 12, 14, 15, 16, 17, and 18). The 11 resident rooms consisted of 2 (two) - four (4) bed capacity rooms, 6 (six) - three (3) bed capacity rooms, and 3 (three) -two (2) bed capacity rooms. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review the facility failed to provide Resident 1 with written notice of a room change before the resident ' s room in the facility was changed, in accordance with the facility ' s policy on Room Change/Roommate Assignment for one of two sampled residents. This deficient practice resulted in a delay of notification of room change for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility developed a resident centered comprehensive care plan for the care and maintenance of three (3) of three (3) sampled residents with a peripheral venous/central catheter (Resident 1, 2, and Resident 3) These deficient practices had the potential to put the residents at risk for intravenous complications without appropriate intervention or preventive measures.