Willow Creek Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for seven of 16 sampled residents (Residents 2, 3, 4, 5, 6, 7, and 8) when:1. Certified Nursing Assistant (CNA) 1 did not discard soiled linens from Resident 2 who was on contact isolation (the practice of separating infected patients from others to prevent the spread of infections transmitted through direct or indirect contact) due to shingles (a painful rash illness caused by the varicella-zoster virus) to a designated isolation barrel (storage unit designed to contain infectious materials and waste) in the soiled utility room on 5/13/26 instead CNA 1 tossed Resident 2's soiled linens into a non-isolation red bin in the soiled utility room on 5/13/26. 2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to safeguard and protect residents' personal belongings from admission to discharge at the facility for one of three sampled residents (Resident 1) when Resident 1's personal belongings were not returned on 4/23/26 at discharge. This failure resulted in Resident 1's personal items missing at the time of discharge and for Resident 1's go without her personal belongings necessary to perform her activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, personal hygiene, mobility, and toileting a person performs daily to care for themselves).

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff immediately notified the physician for physical and mental health change of condition for one of three residents, Resident 1, when on 4/8/25 Registered Nurse (RN) 1 did not recognize the physical and mental health decline of Resident 1 brought to her attention by Resident 1's daughter who was at the bedside. RN 1 did not provide the necessary medical notification for the altered mental status of Resident 1, symptoms included inability to swallow medications which prompted RN 1 to perform an oral sweep with her fingers, Resident 1's inability to verbally respond, refused breakfast, lunch and dinner which were all changes to Resident 1's baseline condition. RN 1 did not provide a full accurate description and assessment to the physician when the physician was notified of Resident 1's change of condition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice to prevent pressure ulcers (PU- a localized injury to the skin and underlying tissues) for one of four residents (Resident 1) when licensed nurses assessed Resident 1 upon admission on [DATE] and were aware of the Resident 1's high risk for pressure ulcers and did not implement effective interventions to prevent pressure ulcers such as changes for size, dimension, weekly description. Resident 1 was assessed to have a stage 2 (a partial-thickness skin injury that involves damage to the epidermis (outer layer of skin) and extends into the dermis (middle layer of skin) pressure ulcer on 5/5/25 and nurses did not implement interventions to prevent wound progression. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when on 4/23/25 to 5/12/25 ertapenem sodium (antibiotic medication used to treat bacterial infections) medication was not administered via intravenous (IV- Into or within a vein) as prescribed for one of six residents (Resident 1) and no side effects were monitored during the administration of the IV antibiotic medication while in the facility. These failures resulted in Resident 1 not receiving antibiotics as prescribed by the provider and had the potential to contribute to his transfer to a general acute care hospital (GACH) on 5/11/25 and 5/13/25.

Inspectors wroteBased on observation , interview and record review, the facility failed to recognize and appropriately act on a change in condition for one of three sampled residents, Resident 1, when staff were provided a list of medications on Resident 1's admission on [DATE] that included insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) and did not inform the physician. Nursing staff were aware of the diagnosis of diabetes (a disease that occurs when sugar in the blood is too high) and did not closely monitor symptoms of hyperglycemia (high blood sugar), nausea and malaise (general feeling of discomfort) and did not inform the physician of high blood glucose (sugar) measurements. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a homelike environment for eight of 16 sampled residents (Residents 8,43, 62, 72, 95, 104, 108, and 110), when resident rooms had missing thresh holds (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room), holes in the walls were not repaired, wall paper was torn and missing, blood stains and scuff marks were on the walls, strong urine odor, and curtains with blood stains were left hanging. Thes failures had the potential to cause emotional harm and frustration to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four of 24 sampled residents (Resident 17, 110, 203, 404) when: 1. Resident 110's care plan was not updated after droplet isolation (precaution taken for patients with known or suspected to be infected with pathogens transmitted by respiratory droplets that are generate by a patient who is coughing, sneezing or talking) was discontinued. This failure had the potential for Resident 110 to not receive person-centered care to meet his medical and nursing care needs. 2. Resident 17 was ordered and administered divalproex (medication used to treat seizure and prevent migraine headache) medication since 10/19/24 and did not have a care plan for the use of medication and diagnosis. This failure placed Resident 17 at risk of not meeting his care needs. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain professional standards of quality for seven of 32 sampled residents (36, 90, 97, 110, 138, 253 and 405) when: 1. Resident 405 had medication in a medicine cup on her bedside table (serves as a surface for food trays and can hold personal items such as phones, laptops, or books) without a self-administration of medications assessment completed, nor nursing staff present. This failure had the potential to put Resident 405 ' s and other facility residents, safety at risk and her specific needs not being met. 2. Resident 90 ' s Oxygen (O2) order was incomplete and did not specify how many liters (L- a unit of measurement) of O2 she was to receive per minute. This failure had the potential to result in Resident 90 to not receive the required amount of oxygen for her needs. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with current accepted professional principles for three of 20 sampled residents (Resident 29, Resident 33 and Resident 79) when: 1. Resident 79 ' s brand name eye medication used to relieve dryness or pain in the mouth or throat solution was without an open date (date it was opened and first used) and Resident 29 ' s brand name insulin (medication used to control high blood sugar) was without an open date. This failure had the potential for Resident 79 and Resident 29 to receive expired medication and could have resulted in uncontrolled blood sugar, and eye irritation. 2. Resident 33 ' s lorazepam (medication used to control anxiety [a feeling of fear, dread, and uneasiness]) did not have a complete legible medication label. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. The facility had a large clear plastic container with red gelatinous (jelly like substance) without any labels to identify product in container, open date or expiration date was in the kitchen refrigerator. 2. The facility had a large, opened container of mayonnaise without open date or expiration date was in the kitchen refrigerator. 3. The cook did not take the temperature of the tray of cauliflower taken out of the oven during the lunch tray line service. 4. The facility failed to store food in Resident 146's room in a safe manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure Food-Related Garbage and Refuse Disposal for one of three outside trash bins, when one of the trash bins was uncovered, and a large amount of plastic and debris was noted on the ground behind the trash bin. This failure had the potential to attracts animals, insects and pests which could lead to infestations, unsanitary conditions, and the spread of disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for six of 19 sampled residents (Residents' 36, 74, 115, 138, 361 and 554) when: 1. Resident 74 urinary catheter (flexible tube inserted into bladder to drain urine) bag was not covered and was visible to residents and visitors to see. 2. Registered Nurse (RN)1 and Licensed Vocational Nurse (LVN) 9 checked Resident 115 and Resident 361's blood pressure (B/P- measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. 3. Licensed Vocation Nurse (LVN) 7 checked Resident 554's blood sugar (amount of sugar in the blood) and did not provide privacy. 4. Licensed Vocation Nurse (LVN) 7 administered insulin to Resident 36 and Resident 138 and did not provide privacy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report a alleged abuse incident to the California Department of Public Health (CDPH) when two of six sampled residents (Resident 30 and Resident110) were involved in a resident-to-resident altercation without serious injury. This failure resulted in the facility not reporting the alleged violation involving resident to resident abuse within the required timeframe and had the potential for additional allegations of abuse to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs of residents) accurately reflected resident's health and functional status of one of four sampled residents (Resident 17) when Resident 17's use of anxiety medication and diagnoses of migraine was not accurately coded on the MDS assessment. This failure had the potential to result in Resident 17's care needs not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR- The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a admission level screening and if necessary a level ll evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed accurately for one of four sampled residents (Resident 17) when Resident 17 was admitted for hospice care on 11/14/24 and an updated PASRR was not completed. This failure had the potential for Resident 17 not to receive the necessary and appropriate psychiatric treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan for one of three sampled residents (Resident 253) when Resident 253 did not have a care plan for oxygen (O2) andmedication ciprofloxacin (antibiotic medication used to treat bacterial infections in different parts of the body). This failure resulted in no baseline care plan to address the use of ciprofloxcin and had the potential for Resident 253 to not have her oxygen needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 128) was free from accidents, when Resident 128 was smoking and had ashes fall on her shirt and into her wheelchair. This failure put Resident 128 ' s safety at risk and the ashes had the potential to burn the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food prepared in a form designed to meet individual needs for two of nine sampled residents (Resident 20 and Resident 8) when: 1. Resident 20 was not served pureed (food that are pudding-like texture that is smooth, blended) banana and had a physician order for a pureed diet. This failure placed residents with difficulty chewing and swallowing and, on a physician, prescribed pureed diet at risk of choking. 2. Resident 8 served minced meat for lunch on 4/1/25 instead of regular textured diet as ordered by medical doctor (MD). This failure had the potential for Resident 8 to not eat her food which could result to weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 102) had access to a call light when the tap button (a large square button that can be easily triggered by pressure from a hand, elbow used when residents have limited finger strength) call light was found hanging off the left handrail three inches above the floor. This failure resulted in Resident 102 not being able to directly call for help.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was accessible for two of three sampled residents (Resident 1 and Resident 3) when Resident 1 and Resident 3's call light was not within reach on 12/26/2024. These failures had the potential to result in Resident 1 and Resident 3 not being able to access their call light when they needed help and assistance with their activities of the daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain infection prevention and control procedures for four of four sampled shower areas when: 1. Station 1-The women ' s shower had a pair of used gloves and washcloth in the soap bar holder, brown colored substance on the washcloth. The drains had loose hair buildup with paper debris. The men ' s shower had a brown colored substance on the grab bar near toilet seat, a uncovered toilet plunger located beside toilet had a white dried substance on it. A package of wipes used to clean a resident was open and on the floor. 2. Station 2 - The men and women ' s shower drains had dark and grey colored hair and debris in them. The tile floor in women ' s shower had dark brown colored tracks along floor. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents, Resident 1, was free from abuse when Resident 1 expressly stated to Certified Nursing Assistant (CNA) 1 not to check his brief (product used to absorb urine) on 6/7/24. CNA 1 checked Resident 1's brief twice without his permission and in the process physically touched Resident 1's genitals (sexual organs located outside the body). These failures resulted in not honoring Resident 1's expressed refusal of care and could be considered physical and sexual abuse. Resident 1 felt violated, angry, humiliated, and disrespected.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of alleged abuse to the state agency, ombudsman and local law enforcement within the required 24-hour time frame for one of five sampled residents (Resident 1) when on 6/7/24, Resident 1 reported to Licensed Vocation Nurse (LVN) 1 that Certified Nursing Assistant (CNA) 1 violated him. This failure led to the allegation of abuse on 6/7/24 to go unnoticed and unreported by the facility until 6/17/24.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified for a change in condition for one of three residents (Resident 1) when on 5/14/24 Resident 1 was observed to have an acute change in mental status, an abrupt loss of in appetite, weakness, fatigue, and was difficult to arouse. CNA 4 communicated the changes of Resident 1 to the licensed nurse and the license nurse did not assess the resident, did not notify the physician and the Responsible Party (RP-a decisionmaker for the resident) regarding the change in condition. This failure resulted in a delay in physician notification of a change in condition that occurred on 5/14/24 and did not provide the physician the resident assessment to diagnose promptly to treat or transfer Resident 1 to a higher level of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective infection control and prevention program for one of three sampled residents (Resident 2), when Certified Nursing Assistance (CNA) was observed without proper personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and not performing hand hygiene (washing hand or using alcohol base hand rub) while providing care on 6/4/24. This failure had the potential to place Resident 2 at increased risk for an infection with multidrug resistant organisms (MRDO- bacteria (germs) that have developed resistance to multiple types of antibiotics) and had the potential transit infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1 ) was assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered position) prior to installation when Resident 1 had no entrapment risk assessment, physician order, and care plans prior to the use of side rails. These failures had the potential to place Resident 1 at risk for decreased freedom of movement, entrapment and/or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met professional standards for one of three sampled residents (Resident 2) when Resident 2's oxygen (a colorless, odorless, tasteless gas essential to living) flow rate (the amount of oxygen being delivered to the body) was not administered according to the physician order (an order given for specific patient/resident by a health care provider). This failure resulted in Resident 2 oxygen to not be administer according to the physician order.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure staff washed or sanitized their hands before they put on gloves during meal preparation. This had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure 5 of 5 dumpsters were closed and the area around them was free of trash and debris to prevent the potential for vermin and pest attraction. This had the potential to affect all 155 residents who currently resided in the facility.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) level I screening for 1 (Resident #108) of 1 sampled resident reviewed for PASARR.

Inspectors wroteBased on interviews, record review, and document reviews, the facility failed to provide an activity program that met the needs of 1 (Resident #304) of 2 sampled residents reviewed for activities.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to prepare enough food to ensure the planned menu was served for 1 (Resident #8) of 2 sampled residents reviewed for food.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standard of practice for two of six sampled residents (Resident 5 and 6) when facility staff did not follow the physician's order to administer nystatin powder (a medication to treat skin infections). This failure had the potential to cause Resident 5 and 6 to experience moisture associated skin damage to the abdominal folds, armpit, breast, and groin area.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received treatment and care to attain and maintain their highest practical wellbeing for two of four sampled residents (Resident 83, Resident 95) when: 1. Resident 83's nutritional needs were not accurately and consistently assessed on admission and as needed and effective interventions were not identified and implemented for weight loss. 2. Resident 83's assessment and nursing interventions to address pressure ulcer were not monitored and evaluated for effectiveness. 3. Resident 95's nutritional needs were not accurately and consistently assessed on admission and as needed and effective interventions were not identified and implemented for weight loss. These failures resulted in actual decline in physical wellbeing for Resident 83 and Resident 95.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents maintained their usual body weight for two of four sampled residents (Residents 83 and 95) when Registered Dietician (RD) did not conduct accurate nutritional assessments, communicate weight loss to interdisciplinary (IDT) team (members of the care team that include nurses, social workers, doctors, therapists and others) and implement effective actions and services to prevent significant weight loss. The RD and nursing staff failed to accurately document and monitor the daily meal consumption for Resident 83 and Resident 95. These failures resulted in Resident 83 experiencing a 47.9 pound (lbs.) weight loss or 36.7 percent weight loss over a period of 9 months. Resident 83 weighed 130 lbs. on admission on [DATE] and on 4/19/19 weighed 82 1b. For Resident 95 the failure resulted in a 25.3 lb. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 83) remained free from developing pressure ulcers (localized injury to the skin and or underlying flesh usually over a bony area as a result of pressure/friction/shear) when Resident 83 had a known history of recurrent skin breakdown and was not repositioned every two hours and kept clean and dry as per the plan of care to prevent pressure ulcers. Resident 83 was bedridden following a fall that resulted in a hip fracture, after admission to the facility experienced a significant weight loss and nursing failed to conduct accurate skin risk assessments. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food safely when: 1. The kitchen bread rack in dry storage area stored a loaf of garlic bread wrapped in foil, with a date which indicated best [used] by 4/30/19; a loaf of rye bread opened in a plastic bag with no written open date; four bags of hot dog buns taken out of the original packaging with no open date written. 2. A bag of chicken meat was not labeled and dated in the walk-in freezer. These failures placed residents at risk for food borne illness and growth of microorganisms (bacteria).

Inspectors wroteBased on interview and record review, the facility failed to conduct a facility-wide assessment specific to the facility needs when facility assessment did not include a water management plan. This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for water borne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by a bacterium known as legionella. most people get legionnaires' disease from inhaling the bacteria in showers, water facets, water fountain) in an event of an outbreak.

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI -is the specification of standards for quality of service and outcomes, a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards, aims to improve processes involved in health care delivery and resident quality of life) program when: 1. The QAPI program did not develop and implement a water management program as part of the Infection Control Program (cross reference F 838 and F 880). This failure resulted in the facility not having a program in place to reduce the risk of water borne illnesses including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by a bacterium known as legionella. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Wet kitchen towels/rags were hung on a rack on top of one another to air dry and wet towels were touching the kitchen floor. 2. The kitchen did not have a system to monitor the sanitation solution of the red sanitation water buckets used to sanitize the work surface areas used to prepare food. 3. The facility failed to have a facility-wide assessment that addressed the federal expectation to develop a water management program for the risk reduction of Legionella (a water borne bacteria which can cause life threatening pneumonia) and other water-borne pathogens (germs that cause disease) in accordance with CMS letter revision date 7/6/18. [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the resident transfer and discharge notification to a representative of the Office of the State Long-Term Care Ombudsman (an official appointed to represent the elderly and frail's rights under public authorities) for two of five sampled residents (Resident 104 and Resident 338) when: 1. Resident 104 was transferred for hospitalization. 2. Resident 338 was transferred for hospitalization. These failures had the potential to result in inappropriate resident transfer and discharge practices for Resident 104 and Resident 338.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement the plan of care to reflect the care needs for three of 30 sampled residents (Residents 2, 33, and 74): 1. For Resident 33, the facility failed to develop a side rail care plan (a plan that provides direction for individualized care of the resident). 2. For Residents 2 and 74, the facility failed to implement the activities care plan when one-to-one in room visits were not followed. These failures placed the residents at risk of not receiving appropriate, consistent, and individualized care interventions to ensure their well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food services staff had appropriate competencies or safely and effectively carry out the functions of food services when [NAME] 1 and [NAME] 3 were unable to verbalize the thermometer calibration process. This failure had the potential for untrained staff to place residents at risk of exposure to foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy and completeness of medical records for five of 30 sampled residents (Residents 2, 74, 64, 84, and 109) when: 1. Resident 2's independent activities were documented as watching television in her room, when there was no television available for the resident. 2. Resident 74's physician orders indicated resident was receiving hospice (end of life treatment and care) services and the hospice services were discontinued but not reflected on the physician's order report summary. 3. Resident 84's physicians' orders dated 5/1/19 inaccurately indicated appointment scheduled with orthopedic (bone specialist) physician for splint (broken bone stabilizer) treatment and rehabilitation services when those services had been discontinued. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain equipment in safe operating condition when: 1. Five of 24 resident beds had controls that did not work and made squeaking noises. This failure resulted in resident beds that were not safe and fully operational for Residents 14, 75, 27, 87 and 104. 2. There was ice buildup inside the walk in freezer on the plastic freezer door curtains and inside part of the door. This failure had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents right to privacy of medical records for one of 28 residents (Resident 93) when Resident 93's personal and medical information was exposed for anyone to see. This failure resulted in the violation of Resident 93's right to privacy and confidentiality of his medical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for two of 20 sampled residents (Resident 123 and Resident 14) when: 1. Resident 123's bed made loud noises whenever bed repositioning was done and the mattress had lumps which were uncomfortable for Resident 123. 2. Resident 14's bed made a loud noise whenever the bed was lowered. This failure resulted in an uncomfortable and un-homelike environment for Resident 123 and Resident 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of cognitive and functional needs) assessment accurately reflected the resident's status for one of five sampled residents (Resident 104) when Resident 104's thickened liquid diet and oxygen therapy was not coded in Sections K and O. These failures resulted in an inaccurate assessment of Resident 104's MDS assessment and had the potential to result in Resident 104's care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which met professional standards of quality when physician's diet orders were not followed for three of five sampled residents (Resident 57, Resident 91, and Resident 104). 1. For Resident 57, the facility failed to follow physician's diet order for a regular textured diet during lunch meal service on 5/6/19 which result in Resident 57 receiving a mechanical diet instead of a regular diet. 2. For Resident 91, the facility failed to follow physician's diet order for thick liquids (thickened to nectar-thick consistency liquids) when the resident received tea without thickening. For Resident 91 this failure had the potential to result in choking and potential risk for lung infection from aspiration (food or liquid going into the windpipe). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized and ongoing activity programs to meet the needs and interests of two of six residents (Residents 2 and 74). For Residents 2 and 74 the facility failed to provide in room one-to-one visits which had the potential for the residents to experience social isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met when one of two sampled residents (Residents 128) did not have documentation of completed post-dialysis assessments on multiple dates. For Resident 128, this failure increased the potential for the delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through the blood vessel) access sites.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure 1 of 6 sampled residents (Resident 33) remained free from accident hazards when Resident 33's bed had three elevated side rails instead of one elevated side rail as ordered by the physician. This failure had the potential to place Resident 33 at risk for entrapment and serious injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were signed and dated by the attending physician in a timely manner for one of three sampled residents (Resident 45). This failure had the potential for inconsistent care coordination due to inaccurate and incomplete records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs stored were labeled in accordance with the facility Accessing a Multiple-Dose Vial policy and procedure for one of three sampled residents (Resident 47) when Resident 47's open insulin glargine (medication used to treat high blood sugar) pen (a device used to inject insulin) was stored in the medication cart without an open date. This failure had the potential to place Resident 47 at risk of receiving expired insulin which could lead to ineffective control of blood sugar and adverse reactions from expired medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine dental services were provided for one of four sampled residents (Resident 45). This failure had the potential to result in dental problem that could result in unintended weight loss and oral infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve thicken liquids in a form designed to meet individual resident needs and as ordered by the physician for two or four residents (Residents 104 and 91) when their drink (coffee and tea) were not thickened. These failures placed Residents 104 and Resident 91 at risk of choking on liquid and potential risk for lung infections from aspiration (food or liquid going into the windpipe).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician prescribed diets for three of five sampled residents (Resident 57, Resident 91, and Resident 104). 1. For Resident 57, the facility failed to follow physician's diet order for regular textured diet during lunch meal service on 5/6/19 which result in Resident 57 receiving the wrong prescribed lunch meal. 2. For Resident 91, the facility failed to follow physician's diet order for thick liquids (thickened to nectar-thick consistency liquids) which had the potential to result in choking and potential risk for lung infection from aspiration (food or liquid going into the windpipe). 3. [...]