Windsor Gardens Convalescent Hospital

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had the capacity to sign a consent for anti-psychotropic medications (a medication that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of five sampled residents (Resident 62 and Resident 3). This failure violated the residents' right to make an informed decision regarding the use of anti-psychotropic medications and had the potential for Resident 62 and Resident 3 to have unnecessary continuation of psychotropic medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure person centered care plan was implemented for three of six (6) sampled residents:1. When Resident's 16 non-pharmacological (evidence-based, non-chemical, and non-invasive methods used to treat, manage, or prevent health conditions without medication) intervention for pain was not offered prior to pain medication administration.2. Resident's 3 who was receiving nutrition through a gastrostomy tube (G tube, a flexible tube surgically inserted through the abdomen into the stomach for the administration of nutrition, fluids, and medications) head of the bed (HOB)was not elevated to at least 30 degrees during feedings. 3. Resident's 50 indwelling catheter (a tube inserted into the bladder to drain urine) care was done. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices were upheld in the kitchen when: 1. Cups of milk and pineapple stored in the refrigerator were not labeled with preparation or use-by date. 2. A kitchen food scoop was stored in the container of food thickener.3. Apples and onions beyond their use-by date were not disposed of.4. Kitchen Dishwasher (KD) 1 and 2 handled washed dishes with dirty gloves.5. Kitchen aide (KA) handled bread with dirty gloves. These failures had the potential to spread pathogens (a germ that causes disease) to the residents, increasing their risk of developing foodborne illnesses that could lead to medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained in a timely manner from the resident before administering COVID-19 (highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine (a preparation that is used to stimulate the body's immune response against diseases) for two of five sampled residents (Resident 19 and Resident 20) when:The informed consent for the COVID 19 vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 19, was obtained on 01/07/2026, which was 34 days prior to the administration on 02/10/2026. The informed consent for the COVID-19 vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 20 was obtained on 08/27/2025, which was 21 days prior to the administration on 09/17/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the resident's preference to go out on pass (a temporary, therapeutic leave allowing residents to go outside the facility) for one of two sampled residents (Resident 13). This failure resulted in Resident 13's feeling that his concerns were not being heard by staff and had the potential to affect Resident 13's sense of well-being, level of satisfaction with life and feeling of self-worth and self-esteem. [...]

Inspectors wroteBased on interview and record review, the facility failed to:Inform the Primary Care Physician (PCP) as soon as the facility received Resident 96's abnormal laboratory (lab) result of potassium of 5.8 mEq/L (critical electrolyte that helps nerve function, muscle contraction, and maintaining normal blood pressure normal range 3.5-5.5 milliequivalents per liter, mEq/L, a unit of measure) on 3/13/2026 at 8:55 a.m. The PCP was notified at 1:00 p.m. (almost 4 hours after the facility received the abnormal high lab result) for one of one sampled resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the confidentiality of resident medical records when the medication labels for two of two sampled residents (Residents 1 and 74) were left unattended on a medication cart in the facility hallway. This failure had the potential to violate Resident 1 and 74's right to confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pressure relieving device of a low air loss (LAL) mattress was set according to the manufacturer's recommended guidelines for Resident 71. This deficient practice had the potential to compromise the resident's right to a safe, clean, comfortable, and homelike environment and to place Resident 71 at risk for pressure ulcer development and discomfort while in bed.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS- resident assessment tool) pain management section for one of three sampled residents (Resident 23). This deficient practice had potential to cause inaccurate care quality measures and triggered care plan will be inaccurate for Resident 23. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and treatment for one of one sampled resident (Resident 96) by failing to: a. Reassess Resident 96's ongoing use of Bactrim (a prescription antibiotic combination used to treat bacterial infections) and sacubitril-valsartan (medication for congestive heart failure [CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling]), and notify the physician that the electronic medical records (EMR) system triggered a drug-drug interaction (DDI) alert (an alerts that appear on the screen by flagging potential adverse reactions or duplicate therapies during the prescribing process. These alerts appear during medication search or processing allowing clinicians to cancel or override them) due to concurrent use of Bactrim and sacubitril-valsartan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's eyeglasses were kept in working condition for one of three sampled residents (Resident 11). This failure resulted in Resident 11 not being able to see adequately and expressing feeling of frustration from not being able to enjoy his preferred activity. During a review of Resident 11's admission Record, the admission record indicated that Resident 11 was initially admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (loss of blood flow to a part of the brain), alcoholic cirrhosis (permanent scarring that damages the liver and interferes with its functioning), and atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure re- assessment was done each time Resident 6 has a fall and implementation of fall prevention interventions, including timely post-fall reassessment and revision of the care plan, for 1 of 1 sampled resident (Resident 6) who was identified as high risk for falls. This deficient practice has a potential for Resident 6 to have recurrent falls , sustaining injury from fall compromising residents safety. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate documentation of intake and output for one (Resident 8) out of one sampled residents who are on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential to cause fluid overload (excess water in the body) or dehydration (insufficient water in the body) for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's head of the bed was elevated to at least 30 degrees during feedings as ordered for one of three sampled residents (Resident 3), who was receiving nutrition through a gastrostomy tube (G tube, a flexible tube surgically inserted through the abdomen into the stomach for the administration of nutrition, fluids, and medications). This failure had the potential to increase the risk of aspiration (accidentally inhaling food, liquids, stomach acid, or saliva into lungs) in the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed rails zoning was measured for Resident 12 annually or ongoing for bed safety assessments was completed for one of one sampled resident reviewed (Resident 12). This deficient practice had the potential to result in an inability to verify that the bed system remained safe for residents' use and placed the resident at risk for entrapment, injury, and harm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents (Resident 13) by failing to provide an ongoing assessment, monitoring and implementing a person-centered care plan when Resident 13 stated persistent negative feelings related to trauma experience. This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 13. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) rotation of injection sites for three out of three sampled residents (Resident 61, Resident 9 and Resident 57). This deficient practice had the potential to result in lipodystrophy (partial or complete loss of fat) which affects insulin absorption, potential hyperglycemia (high blood glucose) for Resident 61, 9 and 57.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's pharmacist consultant's recommendation in the Medication Regimen Review (MRR), which advised adding a pain medication order for mild or severe pain, was reviewed and acted upon for one of five sampled residents (Resident 3)This failure resulted in Resident 3 not receiving recommended adjustments to her pain medication regimen, increasing the risk for Resident 3 to suffer from unmanaged pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication was not left at the bedside without a physician's order for one of two sampled residents (Resident 15). This deficient practice has the potential risk for medication errors and adverse drug events. During a review of Resident 15's admission Record, the admission record indicated that Resident 15 was initially admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-(a condition in which the heart does not pump blood as well as it should) and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dining Services Manager (DSM) had the appropriate competencies and skills to carry out duties in the kitchen when she incorrectly tested the chorine levels of the dishwasher. This failure had the potential to affect chlorine concentration. Excess chlorine on dishes could lead to chlorine poisoning, while insufficient chlorine could leave germs on the dishes, both increasing the residents' risk of serious illness or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 accurately documented medication administration for one of one sampled resident (Resident 44). This failure had the potential to result in inaccurate medical records, medication documentation errors, and inappropriate clinical decision-making related to medication management.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained in a timely manner from the resident before administering influenza (an infection of the nose, throat and lungs, which are a part of the respiratory system) vaccine (a preparation that is used to stimulate the body's immune response against diseases) for two of five sampled residents (Resident 19 and Resident 20) when: 1. The informed consent for the influenza vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 19, was obtained on 08/27/2025, which was 6 days prior to the administration on 09/02/2025. 2. The informed consent for the influenza vaccine, including a discussion of the risks, benefits, and potential side effects for Resident 20 was obtained on 08/27/2025, which was 21 days prior to the administration on 09/17/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 30) has call light (a device to press, to call and ask for help) within reach. This deficient practice had the potential for Resident 30 unable to ask for help if needed. [...]

Inspectors wroteBased on interview and record review the facility failed to meet the needs of the residents in a timely manner for three of six sampled residents (Resident 1, Resident 2 and Resident 3). For Resident 1, Resident 2 and Resident 3, the facility failed to respond to the call lights and requests for assistance timely. These deficient practices resulted in Resident 1 stating she felt irritated, Resident 2 stated he .was so upset and angry and Resident 3 stated she felt staff do not treat me with respect. 1. During a review of the admission Record indicated the facility admitted Resident 1 on 7/24/25 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and generalized muscle weakness. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 7/29/25 indicated Resident 1 was cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician order for fingerstick to obtain the blood sugar level (BSL, measure of sugar in the blood by using a glucometer [medical device that measures the blood glucose level in the body] for one of six sampled residents (Resident 1) according to the professional standards of quality. For Resident 1, the facility failed to:1. Obtain a physician order to obtain BSL by fingerstick from Resident 1's physician. The fingerstick were done on 7/24/25, 8/2/25, 8/8/25/ 8/9/25, 8/10/25 and 8/11/25.2. Notify the physician when Resident 1's BSL results were above 189 milligrams per deciliter (mg/dL, a unit of measurement for the concentration of glucose in the blood, normal range is between 60 mg./dL to 100 mg./dL). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of one of four sampled residents Resident 1. As a result of this deficient practice Resident 1 fell on 6/19/2025 at 4:40 AM and transferred to General Acute Care Hospital (GACH).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu and provide residents a variety of food options when: 1. Resident 25, who did not want fish, received boiled diced chicken instead of baked chicken per menu. 2. Resident 28, who was on vegan plant-based diet, did not receive vegan options and vegan menu was not prepared. 3. Six residents who were on the renal diet (a diet intended for residents with impaired kidney function. The purpose is to provide adequate nutrition, prevent protein loss and manage fluid and electrolyte balance) received peas instead of oven French fries per menu. These deficient practices had the potential to result in inadequate nutrition status and meal dissatisfaction when the menu was not followed and updated to reflect the needs of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 12 residents on pureed diet received the correct pureed diet texture (foods that do not require chewing and are easily swallowed. Food should be smooth .consistency of pudding) as ordered when the cook served thin and soupy carrots instead of pureed carrots that was homogenous (of the same kind; alike), cohesive and had a pudding like consistency. This deficiency had the potential to result in meal dissatisfaction and increased choking and aspiration risk for residents on pureed diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when one can opener blade was dented and stained with dried brown residue. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in out of residents who received food from the facility.

Inspectors wroteBased on interview and record review, the facility failed to: -Obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (RP - a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment in two of five residents sampled for unnecessary medications (Resident 26 and Resident 10). -Obtain informed consent from the resident or RP after increasing the dose of aripiprazole (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 43). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 27) had the call light within reach. This deficient practice placed the resident at risk for not receiving needed care and placed the resident at risk for falls.

Inspectors wroteBased interview and record review, the facility failed to document for one of six sampled residents (Resident 10) when the nicotine smoking patch (used to help people to stop smoking cigarettes) was removed after usage. This deficient practice had the potential to ineffectively give the proper dosage of medication to Resident 10.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the minimum data set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses), dated 11/21/24, by failing to include a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there), depression (a mental illness characterized by depressed mood, difficulty sleeping, or lack of interest in usually enjoyable activities), and bipolar disorder (a mental health condition that causes extreme mood swings from emotional highs [mania] to deep lows [depression]) per information in the medical record for one of five residents sampled for unnecessary medications (Resident 26.) The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 26 may not have received care planning [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 16 and 10) care plans were revised for Resident 16 who refused to wear hearing aids and for Resident 10 regarding the interventions on when to remove and document the disposal of the smoking patch (skin patches are used to help people to stop smoking cigarettes). This deficient practice had the potential for Resident 16 and 10 to receive insufficient treatment and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled Residents (Resident 22, and Resident 47) received professional standard of care and services to maintain clean fingernails with trim. This deficient practiced placed Resident 22, and Resident 47 at risk for a potential skin injury and bacteria growth of the fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff assisted one of six sampled residents (Resident 16) with hearing aids (a device worn in or behind the ear designed to amplify sound for individuals who have difficulty hearing) place the hearing aid in the resident's ears daily. This deficient practice of not providing hearing aids to Resident 16 had the potential for the resident to not hear clearly and communicate needs to staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 341), who was on a low air loss mattress ([LAL]- a medical device that helps prevent and treat pressure ulcers by distributing body weight and improving air circulation) had the correct setting to prevent skin breakdown (damage to the skin caused by prolonged pressure on bony areas of the body). This deficient practice had the potential to worsen skin breakdown.

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 46) by failing to ensure report to the resident's physician (MD) the presence of sediment (particles in liquid) in the indwelling urinary (foley) catheter (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential to delay the healing of Resident 46's urinary tract infection (UTI; an infection in the bladder/urinary tract) or cause the infection to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Residents 52) received the appropriate treatment and services needed to maintain and prevent gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) complications. Resident 52's GT was not securely connected to prevent leakage. This deficient practice caused feeding to leak from the GT soaking the resident's skin and bed linen, placing the resident at risk for malnutrition and skin break down.

Inspectors wroteBased on interview and record review, the facility failed to ensure signs and symptoms of bleeding and bruising related to the use of aspirin (a medication used to prevent blood clots and Eliquis (a medication used to prevent blood clots) in one of five residents sampled for unnecessary medications (Resident 78). The deficient practice of failing to monitor for signs and symptoms of bleeding during aspirin and Eliquis therapy increased the risk that Resident 78 could have experienced adverse effects (unwanted and dangerous side effects of medication) such as bleeding and bruising leading to medical complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to: -Ensure the antipsychotic medication (a class of medications used to treat mental illness), pimavanserin (an antipsychotic medication used to treat mental illness) was used for a clear indication or diagnosed condition as documented in the clinical record for one of five residents sampled for unnecessary medications (Resident 26). -Ensure the lowest possible dose of the antipsychotic medication, aripiprazole (an antipsychotic medication used to treat mental illness), was used for behavioral management in one of five residents sampled for unnecessary medications (Resident 43). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting two of three residents observed for medication administration (Residents 19 and 48.) The medication errors noted were as follows: -Attempted to administer carbamazepine (a medication used to treat nerve pain) suspension (a liquid medication dosage form in which a solid is suspended, but not dissolved, in a liquid vehicle) without first shaking the bottle to Resident 48. -Administered the wrong formulation of multivitamins (a vitamin supplement) to Resident 19. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its residents were free from significant medication errors by attempting to administer carbamazepine (a medication used to treat nerve pain) suspension (a liquid medication dosage form in which a solid is suspended, but not dissolved, in a liquid vehicle) without first shaking the bottle to one of three sampled residents observed for medication administration (Resident 48). The facility failed to ensure to follow the parameteres (fixed high and low limits in which the blood pressure must be to safely administer the medication) when administering antihypertensive (used to treat high blood pressure) medication for Resident 18. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the treatment nurse (TN) 1 changed gloves after removing a soiled dressing from Resident 13 and applying a clean dressing. This deficient practice had the potential to result in spread of infection and can lead to a delay in wound healing process.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the records upon written request on 1/20/2025 from a legal representative of one of three sampled residents (Resident 1). This deficient practice had resulted in the violation of the rights of Resident 1's family member to obtain copy of the records.

Inspectors wroteBased on interview and record review the facility failed to ensure the medications were given and skin treatment were done for one of three sampled residents (Resident 1). For Resident 1, the facility failed to ensure: 1. Resident 1 ' s skin treatment was done and documented in the Treatment Administration Record (TAR, daily documentation record used by a licensed nurse to document treatments given to a resident) on 12/20/24 and 12/21/24. 2. Resident 1 ' s eyedrops Brimonidine Tartrate 0.2% solution (eye drops used to lower pressure in the eyes of residents who have glaucoma) was administered and documented in the Medication Administration Record (MAR, daily documentation record used by a licensed nurse to document medications given to a resident) on 12/22/24 and 12/23/24. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident ' s wishes for medical care and treatment were clarified with the resident and/or the representative for one of three sampled residents (Resident 1). For Resident 1 who had a do not resuscitate status (DNR, allow natural death) order at general acute hospital (GACH 1), the facility failed to clarify with the family and the physician the code status (designation that communicates the type of emergent healthcare a resident would want or would not want to receive if the heart or breathing stops), when Resident 1 was admitted to the facility on [DATE] and subsequent days. This deficient practice had the potential for the facility to deny and honor Resident 1 and Resident 1 ' s next of kin (NOK) of their right regarding Resident 1 ' s treatment preferences during emergency.

Inspectors wroteBased on interview and record review, the facility failed to permit one of four residents (Resident 1) and implement their Bed-hold policy and procedures (P&P) after Resident 1 was transferred General Acute Care Hospital 1 (GACH 1) and was ready to be transferred back to the facility on [DATE]. The facility did not permit Resident 1 back to the facility. This deficient practice resulted in the Resident 1 remaining at GACH 1 and the potential to cause psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of the two sampled residents (Resident 1) who was on oxygen via nasal cannula (NC-a thin, flexible tube with two prongs at one end that are inserted into the patient's nostrils and provides oxygen through the nose) the tubing was changed weekly and off the ground per the facility's policy and procedures (P&P) titled Changing of Nasal Cannula/Oxygen Tubing, This deficiency practice had the potential to result in Resident 1 contracting pneumonia (an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses, and fungi, can cause pneumonia).

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection prevention and control practices needed to prevent/control the spread of infections, by failing to: a. Ensure Certified Nurse Assistant (CNA 1) wore gloves when entering a novel respiratory isolation precaution (isolation room that requires staff and visitors to wear a gown, gloves, face shield and a N-95 mask [disposable respirator mask]) room for one of three sampled residents (Resident 1). b. Ensure CNA 1 doffed (removed) her face shield and N-95 mask after leaving a novel respiratory isolation precaution room (Resident 1 ' s room). These deficient practices had the potential to result in an increased spread of infection to facility residents and staff.

Inspectors wroteBased on observation, interview,and record review the facility failed to ensurea Registered Nurse (RN) was available to work (excluding the DON) as federally required for at least 8 consecutive hours a day from 7/1/2024 to 7/18/2024. This deficient practice placed all 85 residents in the facility at risk for delayed care and services, missed treatments and/or medications, and a potential delay in emergency care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement and individualized and comprehensive care plan (CP) to meet individual needs for two of six sampled residents (Resident 1 and Resident 2) by failing to: a. Ensure a CP was developed timely for Resident 1 ' s indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). b. Ensure that a comprehensive CP was developed and implemented for Resident 2 ' s self-administration of medication. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of six sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure a physician ' s order dated 6/21/2024 indicating Resident was to be seen by a Neurologist (a medical doctor who diagnoses, treats and manages disorders of the brain and nervous system) on 6/24/2024. Resident 1 was not seen by the Neurologist. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of one sampled resident (Resident 1) by failing to ensure Resident 1 ' s indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services for one of six sampled residents (Resident 2) by failing to: a. Ensure that Resident 2 ' s medications were not left unattended at the bedside. b. Ensure a self-administration assessment was completed when Resident 2 was observed with own medications at bedside: calcium carbonate tablet (Tums - antacid used to relieve heartburn, sour stomach, acid indigestion, and upset stomach) and lactulose oral solution (treats constipation and liver disease). c. Ensure that a comprehensive care plan (CP) was developed and implemented as indicated in the facility ' s policy and procedure (P&P). This deficient practice had the potential to result in Resident 2 in unintended complications related to the management of medications.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA) within two hours for one of two sampled residents (Resident 1). Resident complained of pain to right upper leg which resulted in a fracture. This deficient practice resulted in a delay of an onsite inspection by the SSA and had potential for ongoing injuries for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of Dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's activities of daily living), had a history of wandering (a common behavior in those with dementia, walking aimlessly with no real place to go and becoming confused with their location), and was a risk for falls, was provided with the necessary care and services by failing to: -Develop a comprehensive care plan for Resident 1's diagnosis of Dementia, including supervision to prevent injury. -Complete a wandering assessment and fall risk assessment quarterly. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice by failing to ensure three of four nursing staff (Licensed Vocational Nurse 1-LVN1, Licensed Vocational Nurse 2-LVN2) and Licensed Vocational Nurse 4-LVN4) was using the facility ' s vital signs (VS-clinical measurements, specifically heart rate, temperature, respiration rate and blood pressure that indicate the state of a patient ' s essential body functions) equipment provided to the staff. This deficient practice had the potential to negatively impact the delivery of care service provided to all the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services in compliance with accepted professional standards of practice by failing to ensure three of four nursing staff (Licensed Vocational Nurse 1-LVN1, Licensed Vocational Nurse 2-LVN2) and Licensed Vocational Nurse 4-LVN4) was using the facility ' s vital signs (VS-clinical measurements, specifically heart rate, temperature, respiration rate and blood pressure that indicate the state of a patient ' s essential body functions) equipment provided to the staff. This deficient practice had the potential to negatively impact the delivery of care service provided to all the residents.

Inspectors wroteBased on interview and record review, the facility staff failed to ensure physician (MD) was notified concerning the change of conditions (COC/CIC) for two of two sampled residents (Residents 3 and 6) when: 1. Resident 3 had multiple episodes of refusing medications. 2. Resident 6 complained of feeling weak. These deficient practices had the potential to result in possible delayed provision of necessary care and services to Resident 3 and 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of two sampled resident (Resident 4). This deficient practice violated Resident 4's right to have grievance addressed.

Inspectors wroteBased on interview and record review, the facility staff failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of 12 sampled residents (Resident 3) by failing to ensure Resident 3's episodes of refusing medications were care planned. This deficient practice had the potential to result negative impact on Resident 3's health and safety, as well as the quality of care and services Resident 3 received.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely administer medications per facility policy to one of one sampled resident (Resident 11). This deficient practice had the potential to result in medication ineffectiveness and place Resident 11 at risk for unsafe, and improper medication administration use.

Inspectors wroteBased on interviews and record review, the facility failed to ensure there was a facility policy developed and implemented to verify whether residents had been provided informed consent or given refusal for the use of psychotropic medications. The facility had inconsistent procedures in documenting informed consent verification for five (5) of 5 sampled residents (Residents 1-5). The facility failed to ensure the interdisciplinary team (IDT, a team of healthcare providers that plan, coordinate and deliver personalized health care to residents) would meet periodically to conduct evaluation of residents on psychotherapeutic medication therapy as per policy and guidance, for 2 of 5 sampled residents (Residents 1 and 2). These deficient practices had the potentials of medication errors and unnecessary medications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure there were descriptive documentations of residents ' behavior episodes and significant specific behavior for one (1) of 5 sampled residents (Resident 1). The facility failed to ensure there were documentations of clinical justifications to decline gradual dose reduction (GDR, a process of tapering) on the dosages of psychotherapeutic medications, for 3 of 5 sampled residents (Residents 1, 4, and 5). The facility failed to ensure there was an order to monitor behaviors being treated with psychotropics for 3 of 5 sampled residents (Residents 3, 4, and 5). These deficient practices had the potentials of unnecessary medications and/or medication error. (Refer to F558)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide means of communication for a non-verbal resident, one (1) of 5 sampled residents (Resident 1). This deficiency had a potential to hinder the communication between the resident and facility staff, which may affect or cause a delay in care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary assessments, care, and services for one of three residents (Resident 1) to prevent falls, by failing to ensure two staff transferred Resident 1 from wheelchair (WC) to bed. On 2/25/2024, certified nurse assistant 1 (CNA 1) attempted to transfer Resident 1 from a WC to a bed without the assistance of another staff member. As a result, on 2/25/2024, Resident 1 fell from the WC onto the floor sustaining right eye injury. Resident 1 required emergent transfer to general acute care hospital 1 (GACH 1) via 911 (emergency response telephone number). [...]

Inspectors wroteBased on interview and record review the facility failed to give Carbidopa/Levodopa 25-100 mg (milligrams) po (by mouth) four times a day for Parkinson ' s disease without dyskinesia, with fluctuations (a progressive disease of the nervous system marked by tremors, muscle stiffness, and slow, imprecise movements- without dyskinesia- unwanted movements such as rapid jerking, muscle spasms and rhythmic, dance like movements) on 2/22/2024 and 2/23/2024 for one of three sampled residents, Resident 1. This deficient practice may have placed Resident 1 at risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged abuse of a resident (Resident 1) to the California Department of Public Health (CDPH) immediately or within 2 hours. This deficient practice placed Resident 1 and other residents at risk for potential repeated abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' clinical records contained their advance directive (written statements 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) acknowledgement forms for ten of ten sampled residents (Resident 3, 9,15, 28, 34, 39, 40, 55, 58, 59). This deficient practice had the potential to cause conflict with a resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive plan of care with measurable objectives and interventions for six of twenty sampled residents (Residents 9, 15, 39, 51, 58, 17) when the facility failed to: -Develop a plan of care that addressed the administration of insulin (a hormone that lowers the level of glucose[a type of sugar]in the blood) and antibiotics (a medicines that help stop infections caused by bacteria) for Resident 9. -Implement Resident 15's plan of care for pain management and notify the physician. -Develop a plan of care that addressed the administration of insulin (a hormone that lowers the level of glucose[a type of sugar]in the blood) and anticoagulants (a medication that is used to prevent and treat blood clots in blood vessels and the [NAME]) for Resident 51. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) actual hours worked by licensed staff providing direct care to the residents per shift. As a result, residents and visitors did not know the accurate number of hours of staff working.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided showers to one sampled resident (Resident 58) according to his choices. This deficient practice had the potential to affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Verification Informed Consent (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) form was fully completed for psychotropic (medications that affect the mind, emotions, and behavior) medications for two sampled residents (Resident 20 and Resident 35). This deficient practice violated the resident's right to be informed regarding the risks and benefits of psychotropic medication therapy, possibly resulting in diminished overall physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) preadmission screening and annual resident review (PASARR) assessment form was completed to determine the facility's ability to provide the special need of the resident. This deficient practice placed the residents at risk of not receiving necessary care and services needed for a new mental illness diagnosis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a communication device or communication board with the language that the resident was able to understand for one sampled resident (Resident 40). This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply the correct setting for the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) for two of two sampled residents (Resident 28 and 58). This deficient practice had the potential to place the resident at risk for discomfort and development of pressure ulcers/injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of one sampled resident (Resident 27) by failing to ensure Resident 27 had a date on the nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) to ensure prompt weekly changing of the nasal cannula. This deficient practice had the potential to cause complications associated with oxygen therapy, including infections or respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened medications were labeled with an open date, affecting Residents 5, 15 and 186 in two of three inspected medication carts (Medication Cart 1 and Medication Cart 3). This deficient practice caused an increased risk that the above listed residents could have received medication that had become ineffective or toxic due to improper labeling.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of four sampled residents (Resident 1) by failing to ensure documentation after wound care treatment was performed. This deficient practice had the potential to result in miscommunication among staff about Resident 1 ' s wound care treatment.

Inspectors wroteBased on interview and record review, the facility failed to assist one of four sampled residents (Resident 2) in ensuring she goes to her appointments. This deficient practice resulted to Resident 2 missing two doctor appointments, which had the potential to negatively affect the resident ' s physical wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food preferences were met for two of three sampled residents (Residents 2 and 4). This deficient practice had the potential for the residents consuming less food than their body needed, which could lead to weight loss and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the call light (a device used by a resident to call for help) is within reach for one of three sampled residents (Resident 4) who had a history of quadriplegia (a symptom of paralysis that affects all a person's limbs [arms and legs] and body from the neck down). This deficient practice had the potential to delay staff from responding to Resident 4 ' s request for help.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to one of four sampled residents (Resident 1) by failing to ensure Resident 1 ' s baclofen (muscle relaxant medication) was ordered by a physician and accurately dispensed and administered per facility policy. This deficient practice had the potential for medication errors which can possibly compromise Resident 1's safety if taken too much.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to one of four sampled residents (Resident 1) by failing to ensure Resident 1 ' s self-administered medications were properly stored and secured inside the room. This deficient practice had the potential to compromise securement of Resident 1's medication and possible safety issues to other residents when left unsecured.

Inspectors wroteBased on interview and record review the facility failed to a. investigate an allegation of financial abuse. b. submit 5-day investigation summary to the California Department of Public Health (CDPH) for one of three sampled Residents, Resident 1. These deficient practices could have led to continued alleged abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) for one out of seven sampled residents (Resident 1) after Resident 1 and family members 1 and 2 (FM 1 and FM 2) complained of itching and discomfort since 7/2023. The facility was aware Resident 1 was continuously itching and scratching for four months despite being treated with hydrocortisone (medication used to treat redness, itching, swelling, or other discomfort caused by skin conditions) and Atarax (medication to treat itching). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) remained comfortable and free of itching by failing to notify a physician and follow up on a dermatology consult after the facility was aware that Resident 1 continued to itch and that family members 1 and 2 (FM 1 and FM 2) had complained that Resident 1 had been scratching and complaining of discomfort since 7/2023. The facility was aware Resident 1 was continuously itching and scratching for four months despite being treated with hydrocortisone (medication used to treat redness, itching, swelling, or other discomfort caused by skin conditions) and Atarax (medication to treat itching). [...]