Woodland Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 4). This deficient practice had the potential to delay the provision of services and resident's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff implemented and documented the required 72-hour monitoring (closely observing and evaluating a resident for three days after something important changes in their health) following a change in condition for two of four sampled residents (Resident 2 and Resident 3). This failure had the potential to delay the identification of a worsening clinical condition, timely physician notification and the implementation of necessary interventions. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster's (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) surrounding floors had trash and litter. This failure had potential to attract birds, flies, insects, pests (animal or microorganism that has a negative effect on humans) and possibly spread infection to 138 of 138 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) by failing to ensure the hot water tank was flushed monthly. This failure placed the residents, staff and visitors at risk for exposure to unsafe water conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for the use of continuous glucose (sugar) monitoring (CGM-glucose monitor uses a sensor that is placed on the back of the upper arm and worn externally by the user, allowing glucose information to be monitored using a mobile application; the hand held reader is used to scan the glucose without the need to prick the fingers) for one of one sampled residents (Resident 145). This deficient practice had the potential to result in inaccurate blood sugar readings due to the lack of training provided to the licensed nurses on the functionality of the CGM device which could negatively affect management of Resident 145's diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for seven (Resident 58, Resident 84, Resident 125, Resident 15 and Resident 9, Resident 101, Resident 4) of nine residents investigated for accidents by failing to: 1. Ensure Resident 58, 84, 125, and 15 did not have an over-bed table on top of the landing pad (a mat placed on the floor next to a resident's bed or chair to minimize the impact of a fall). 2. Ensure Resident 9's bed was left in its lowest position 3. Ensure Resident 101's bed upper side rails (adjustable metal or rigid plastic bars that attach to the bed) were fully covered by padding per the physician's orders. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional care and services consistent with resident's nutritional assessment and physician orders for one of two sampled residents (Resident 145) by failing to: 1. Ensure weekly weight monitoring was conducted in accordance with physician's order. 2. Ensure that the nutritional assessment conducted by Registered Dietician's (RD- expert on diet and nutrition) was completed in accordance with physician's order. These deficient practices had the potential to result in further risk of weight loss for Resident 145.

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor a resident's pain every shift per the physician's order for one of seven sampled residents (Resident 101). This deficient practice had the potential to result in undetected, untreated, and unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance and palatable temperatures when: a. The grilled bratwurst (a fresh German sausage traditionally made from pork, veal, or beef, seasoned with spices like marjoram, nutmeg and pepper) had black burnt ends. b. Hot foods were not at palatable temperatures for breakfast on 6/2/2026. c. Turkey patty was dry for easy to chew (diet consist of soft, tender, and moist food that require minimal biting and less chewing effort) diet. These failures had potential to result in 128 of 138 facility residents including Resident 155, Resident 72, Resident 157, and Resident 120 at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Kitchen and storage areas were not free from dirt and debris. Reach-in refrigerator shelves contained dried food debris and amber discoloration particles. Walk-in refrigerator floors had dry spills, red Jello pieces, butter and trash. Walk-in refrigerator shelves had dried up milk residues. Dry storage floor contained oatmeal particles Cambro (a brand name of container that are insulated or durable plastic commonly used in restaurants, hospital and catering) containers had sticker residues Drying racks for domes had dirt residues. Freezer gasket was torn. No thermometer on the chest freezer 1. Three (3) dented cans were found with non-dented cans. [NAME] chopping boards had burnt marks, cracked and scratches. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for 3 (Resident 1, Resident 5, and Resident 18) of 29 sampled residents by failing to: Ensure the diagnosis of diabetes mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) was reflected in Resident 1's and Resident 5's list of diagnoses in the medical record. This failure had the potential to result in inaccurate medical records, missed care planning, and inadequate treatment and management of the residents' diabetes. 2. Ensure Restorative Nursing Assistant 1 (RNA 1, a certified Nursing Assistant with specialized training in physical rehabilitation) documented a treatment until after it was completed and did not document the treatment before it was provided for Resident 18. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when three (3) flies (a type of insect) were observed in trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) and dishwashing area in the kitchen. This failure had the potential to result in 128 of 138 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted resident dignity and respect for two of 29 sampled residents (Resident 22 and Resident 4) when: 1. The facility failed to inform Resident 22 of the reason for the use of single-use disposable food containers and plastic utensils when serving meals. This deficient practice had the potential to violate the resident's rights to be treated with respect and dignity and negatively affect resident's sense of self-worth and self-esteem. 2. Speech Therapist 1 (ST 1, a healthcare professional who evaluates and treats swallowing disorders in residents) was observed standing over Resident 4 while assisting with eating. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the full six page of the arbitration agreement (a voluntary binding agreement by the parties to submit to an arbiter [a lawyer or retired judge, not a court judge] all or certain disputes which have arisen or may arise for a resident while staying in the facility) for one of four sampled residents (Resident 154). This deficient practice violated Resident 154's rights to make a fully informed decision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a safe, clean, comfortable, and homelike environment for one of 29 sampled residents (Resident 58) when the over bed table was wobbly and missing one wheel. This deficient practice violated the resident's right to a safe, clean, comfortable and homelike environment and had the potential to affect the resident's self of worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled resident's (Resident 1 and Resident 5) diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) was reflected in the resident's list of diagnoses in the Minimum Data Set (MDS - a resident assessment tool). This deficient practice resulted in Resident 1 and Resident 5 having an inaccurate MDS assessment and has the potential to negatively affect in plan of care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plan (a document that summarizes a resident's needs, goals, and care/treatment) for two of five sampled residents (Resident 1 and Resident 5) for diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and the administration of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections. This deficient practice had the potential to result in a delay of nursing care and medical interventions for Resident 1 and Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of one resident (Resident 101) investigated under the communication-sensory care area by failing to ensure Resident 101 received proper evaluation for hearing loss. This deficient practice had the potential for Resident 101 not to receive necessary medical treatments or assistive accommodation to maintain or improve their hearing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM or LAL, a mattress designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight for one of one sample resident (Resident 156) investigated for pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice placed Resident 156 at risk for development of new pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and complete the fall risk factors in the Nursing Documentation Evaluation for three of five sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to place the residents at increased risk for injury related to falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when [NAME] 1 and [NAME] 3 did not completely air dry the pans before using it in during food preparation. This deficient practice had a potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses (diseases caused by consuming food or drinks that are contaminated by germs or chemicals) in 128 of 132 medically compromised residents who received food and ice from the kitchen. Cross reference to F812.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents' meals at regularly scheduled times in accordance with resident needs, preferences, and requests when Station 3's last meal cart was served late during breakfast on 5/1/2026. This deficient practice had the potential to result in hunger and frustration for 35 of 55 residents including Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when kitchen staff did not air dry pans before using the pans in trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). This deficient practice had a potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in of 128 of 132 medically compromised residents who receive food and ice from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the admission Minimum Data Set (MDS - a resident assessment tool) accurately reflected the resident's status for one of four sampled residents (Resident 1). This deficient practice had the potential to result in delayed or inadequate delivery of care and services for Resident 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the body weight of one of three sampled residents (Resident 1) was accurately documented in the medical record. This deficient practice had the potential to result in delays in care and services for Resident 1, as well as a decreased quality of care and overall health status.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice by:1. Failing to ensure a reassessment was completed for Resident 1 on 4/14/2025 during the day shift (7 a.m. to 3 p.m.) following a change in condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) on 4/13/2025.2. Failing to ensure Resident 1's Medical Doctor 1 (MD 1) was notified that Resident 1 refused to provide a urine sample for a urinary analysis (UA- a laboratory test used to analyze urine levels for possible infections) and a urine culture and sensitivity (C&S- a laboratory test used to identify bacteria or yeast in the urine and determine the most appropriate medication for treatment of an infection). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had accurate information documented on the Change of Condition form (COC form - a form used by the facility to document changes in resident's condition including actions taken and notification of the physician and responsible party) by failing to document the correct time that Resident 1's Medical Doctor (MD) was notified of Resident 1's change of condition on 4/13/2025. This deficient practice had the potential to delay necessary treatment, care and services placing Resident 1 at risk for a decline in overall health status.

Inspectors wroteBased on interview and record review, the facility failed to implement a resident's comprehensive care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of nine sampled residents (Resident 2) when Licensed Vocational Nurse 3 (LVN 3) failed to accurately document the administration of pyridoxine hydrochloride (a form of vitamin B6, used to treat and prevent vitamin B6 deficiency) in the medication list sheet (created by the facility to validate that Resident 2 received medications at the scheduled times). This deficient practice had the potential to create confusion among licensed staff regarding the administration of pyridoxine which could result in ineffective delivery of care and services to the resident.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs for one of five sampled residents (Resident 2) by failing to: 1. Ensure Licensed Vocational Nurse 2 (LVN 2) administered methocarbamol (a prescription muscle relaxant used to relieve pain and discomfort from muscle spasms [or cramp, when a muscle suddenly and forcefully tightens up on its own, often feeling like a painful knot or twitch]) and gabapentin (used to treat nerve pain) in a timely manner per the physician's order for the scheduled dose at 9 a.m. and 1 p.m. for Resident 2. 2. Ensure the licensed nurses removed Resident 2's lidocaine external patch (a sticky, flexible pad placed on the skin to help relieve minor aches and pain) four (4) percent (% - unit of medication strength), or lidocaine 4% patch, as per the physician's order. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow-up and cancel a resident's transportation for a cancelled appointment for one of five sampled residents (Resident 1). This deficient practice resulted in Resident 1 being transported to an appointment that was cancelled.

Inspectors wroteBased on interview and record reviewed, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 3), by failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not falsify blood pressure entries in Resident 3's Medication Administration Record (MAR, a report detailing the medication administered to a resident by the licensed nurses) on 12/1/2025, 12/8/2025, 12/9/2025, 12/12/2025, and 12/15/2025. This deficient practice had the potential to affect appropriate medication administration due to the inaccurate blood pressure documentation in Resident 3's medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to administer Resident 1's midrodrine (medication to treat low blood pressure [hypotension]) as prescribed by the physician. This deficient practice resulted in the omission of midodrine which could have resulted in Resident 1 experiencing a hypotensive (low blood pressure) episode.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a bottle of ketoconazole 2% shampoo (used to treat a variety of infections caused by fungus or yeast) was secured in a medication cart and not left unattended on top of a toilet in a resident shared restroom for one of three sampled restrooms. This deficient practice had the potential for unauthorized use of the medication, which could result in a negative impact to the health, and well-being of residents and increases the risk of contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's attending physician documented a resident's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) within 72 hours following admission for one of three sampled residents (Resident 1). This deficient practice had the potential for inconsistent care coordination due to incomplete medical records for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a nutritional supplement drink per physician's order for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to receive insufficient food intake which could result in weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of three sampled residents (Resident 1 and Resident 2) with meals that accommodated their food preferences. This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's physician regarding a resident's Systane (used to relieve burning, irritation, and discomfort caused by dry eyes) night ophthalmic (relating to the eyes) gel not being available and not being administered for one of four sampled residents (Resident 1). This deficient practice had the potential to result in worsening symptoms and negatively affect the delivery of care and services to Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 1) by failing to accurately document Resident 1's blood pressure (BP - a measure of how well blood circulates through your arteries [pathway that carries blood away from the heart]). This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards by failing to accurately document Resident 1's Restorative Nurse Aide (RNA, a program designed to ensure each resident maintains their physical and functional abilities) treatment. This deficient practice had the potential to result in decline in Resident 1's activity of daily living (ADLs- activities related to personal care) and create confusion regarding the delivery of care and services provided to the resident. [...]

Inspectors wroteBased on interview, and record reviews, the facility failed to manage a resident's pain by failing to administer his scheduled pain medication as ordered by the physician for one of three sample residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1`s psychosocial wellbeing and quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to accurately provide pharmaceutical services to one of three sampled residents (Resident 1) by failing to: 1. Administer oxycodone-acetaminophen (a medication to relieve moderate to severe pain) oral tablet 7.5-325 milligrams (mg-a unit of measurement of mass) to Resident 1 on 6/14/2025 at 6:00 a.m., as prescribed by the physician. 2. Ensure LVN 3 did not document administration of oxycodone-acetaminophen oral tablet 7.5-325 mg on 6/14/2025 at 6:00 a.m in Resident 1's Medication Administration Record when it had not been given. These deficient practices had the potential for harm to the resident due to inaccurate records of narcotic use; and increased the risk of controlled drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records in accordance with the accepted professional standards for one of three sampled residents (Resident 1) when on 6/14/2025, Licensed Vocational Nurse 3 (LVN 3) documented in the Medication Adminsitartion Record ( (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) that she administered Resident 1`s pain medication when it had not been given. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical care information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 71) with known food allergies (a substance that causes an allergic reaction [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances]), was not served food containing allergens, by: 1. Serving for breakfast, on 4/8/2025, cream of wheat (a type of hot cereal that contains gluten [a protein found in the wheat plant and some other grains]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses to assist a patient when in need) was within residents` reach while in bed for three of three sampled residents (Resident 12, Resident 133, and Resident 292). This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for the use of bed siderails for three of seven sampled residents reviewed for side rail use (Resident 42, 12, and 38) This deficient practice had the potential for the resident to not receive the necessary care and services to prevent potential injury from use of bed siderail. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injections sites to three of three sampled residents (Residents 27, Resident 116 and Resident 38) reviewed under the insulin care area. This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 27, Resident 116 and Resident 38).

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment and services to prevent the formation and progression of a pressure ulcer (an injury to skin and underlying tissue due to prolonged pressure over a bony structure) to one of three residents (Resident 37) reviewed for pressure ulcer by failing to: 1. Measure Resident 37's unstageable pressure ulcer (pressure injury [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence] where the base of the ulcer is obscured by slough or eschar [dead or black tissue similar to a scab], making it impossible to determine the depth of the tissue damage) for one week (week of 3/12/2025). 2. Provide a wound treatment to Resident 37's unstageable pressure ulcer on 3/15/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards to two of two sampled residents (Resident 443 and 125) by: a. Failing to ensure Resident 443's room is free of hazards by having a long, looped cable exposed above the head of the resident's bed and within his reach. b. Failing to place landing pads (a floor pad designed to help prevent injury should a person fall) on both sides of Resident 125's bed as ordered by the physician. These deficient practices placed Resident 443 and Resident 125 at increased risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Antibiotic or Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse) coincided with the bubble pack (a medication packaging system that contains individual doses of medication per bubble) for three of three sampled residents (Residents 26, 62, and 111). These deficient practices had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 27 total opportunities contributed to an overall medication error rate of 7.41% affecting two (2) of four (4) residents (Resident 8 and 55) observed for medication administration. The medication errors were as follows: 1. Resident 8 received lidocaine (a medication used to relieve pain) patch (a medication delivery system) applied to one (1) wrist instead of both, as ordered by Resident 8's physician. 2. Resident 55 did not receive Omega 3 (a medication used to support overall health and well-being, such as heart and kidney health, brain function, and reducing blood lipid [fat] levels) as ordered by Resident 55's physician. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injections sites to three out three sampled residents (Residents 38, Resident 116, and Resident 38) reviewed under the insulin care area. This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 38, Resident 116 and Resident 38. Cross reference to F658. 2. Follow the hold parameters for midodrine (a medication to elevate blood pressure for those with low blood pressure) as ordered by the physician for one of six residents (Resident 12) reviewed for unnecessary medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. Two (2) of 2 staff served cream of wheat to a resident (Resident 71), who was allergic to gluten. 2. There was no training provided to staff regarding gluten free diet. These failures resulted in Resident 71 being served cream of wheat which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]), diarrhea, dehydration and/or death for Resident 71.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility kitchen staff or licensed nurses checked the contents of a meal tray against the meal tray ticket (form that indicates the specific meal being served to a resident based on their dietary restriction and preference) during breakfast on 4/7/2025 for one of 142 residents (Resident 18) served meals from the kitchen. This deficient practice had the potential to place residents at risk for anaphylactic reaction (a severe, life-threatening allergic reaction that can develop rapidly) which could then lead to hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance when: a. Pineapple Bavarian was at 70 degrees Fahrenheit (°F, a scale of temperature) and puree pineapple Bavarian was at 73°F. b. Cheese enchilada was crunchy, hard, dry and lacking sauce. c. Liquid was coming out from the puree mixed vegetables This deficient practice placed 97 of 149 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) except consistent carbohydrate diet ([CCHO], a diet with the same amount of carbohydrate each meal) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) cheese enchilada was grainy, puree rice had rice grains and puree vegetables did not hold it shape with liquid coming out from the product These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 11 of 97 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Kitchen equipment and utensils were not maintained in its proper condition, smooth and easy to clean. 1. Three (3) of four (4) racks were corroded with amber discoloration in the walk-in refrigerator. 2. Four (4) of seven (7) racks were corroded with amber discoloration in the dry storage room. 3. Fifty (50) of 50 resident's cracked trays. b. Kitchen equipment and kitchen areas were not cleaned and sanitized. 1. Walk-in refrigerator floors had food such as orange, piece of bread, piece of cream cheese, sandwich spread and dirt debris. 2. Walk-in freezer had food debris on the floor. 3. Chest freezer ledge opening had dust buildup and door was sticky to touch. 4. Walk-in refrigerator gasket had dirt buildup. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when there were 15 soiled gloves, an empty bottle spray, plastic, and other trash on the floor and one (1) of three (3) dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) had dirt and brown food spills. These failures had a potential to result in attracting birds, flies, insects, pest and possibly spread infection to 142 of 149 facility residents.

Inspectors wrote2.a. During a review of Resident 94's admission Record, the admission Record indicated the facility admitted the resident on 1/27/2023 with diagnoses including hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and spinal stenosis (the spaces inside the bones of the spine get too small). During a review of Resident 94's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact and required supervision or touching assistance with shower, dressing, and putting on/taking off footwear. During a concurrent observation and interview on 4/7/2025 at 10:52 a.m., with the IP, observed with the IP, Resident 94 lying in bed and a plastic urinal bottle at Resident 94's bedside. Observed the plastic urinal bottle had no written identifier indicating that it belonged to Resident 94. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident`s personal belonging was returned to the resident's representative following the resident`s death for one of one resident (Resident 141). This deficient practice violated the resident`s right to have his possessions protected and accounted for.

Inspectors wroteBased on observation and interview, the facility failed to ensure to provide the name of the medication and its indication (reason for the use of the medication) prior to administration of the medication, affecting one of four residents (Resident 8) observed for medication administration. This deficient practice violated Resident 8's rights to make decisions regarding their medication regimen, withhold treatment or seek alternatives, potentially resulting in psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to involve the resident and or the resident`s representative in the quarterly Interdisciplinary Team (IDT- involves nurses collaborating with other healthcare professionals from various disciplines to provide comprehensive patient care) Care Conference for the development of an individualized Comprehensive Care Plan (a document that outlines a person's healthcare or support needs, how those needs will be met, and by whom) for one of one sampled resident (Resident 99). This deficient practice resulted to Resident 99's frustration due to being unable to participate in the care plan meeting to discuss the resident's discharge plan and goals.

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedure, Theft/Loss Report, by failing to report an allegation of misappropriation of resident property no later than 24 hours, to the State Survey Agency (California Department of Public Health [CDPH]), the ombudsman (advocate who ensures the rights and well-being of residents) and the local law enforcement agency for one of three sampled residents (Resident 38). This deficient practice had the potential to result in unidentified financial abuse in the facility and failure to protect residents from financial abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an allegation of misappropriation of money was thoroughly investigated for one out of three sampled residents (Resident 38). This deficient practice had the potential to result in unidentified financial abuse in the facility and failure to protect Resident 38's from misappropriation of property.

Inspectors wroteBased on interview, and record review the facility failed to: 1. Review and update a care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a resident`s fall for one of one sampled resident (Resident 125) reviewed under fall care area. This deficient practice had the potential to result in Resident 125 receiving inadequate care and supervision at the facility. 2. Review and update a care plan after discontinuation of oxygen therapy for Resident 6. This deficient practice had the potential to result in Resident 6 receiving inadequate care at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident unable to carry out ADLs receive the necessary services to maintain grooming and personal and oral hygiene to one of two sampled residents (Resident 113) by failing to change Resident 113's clothing for three days and ensure Resident 113's clothing was free of food stains.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 49) with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to provide indwelling catheter care to the resident every day and as needed (PRN), and monitor the resident for signs and symptoms of infection and skin irritation as indicated in Resident 49's care plan (a document outlining a detailed approach to care customized to an individual resident's need). These deficient practices had the potential to result in Resident 49 developing urinary tract infections (UTI-an infection in the bladder/urinary tract) and other health complications related to the use of an indwelling catheter.

Inspectors wroteb. During a review of Resident 58's admission Record, the admission Record indicated that the facility admitted Resident 58 on 3/8/2025, with diagnoses including aftercare following surgical amputation of right second and third toes (the surgical removal of a body part), acute osteomyelitis (an infection in the bone), and type two diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). During a review of Resident 58's History and Physical (H&P) dated 3/11/2025, the H&P indicated that Resident 58 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store one (1) opened budesonide (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (package made of foil protecting the inhalation solution from light and degradation) for one of one sampled resident (Resident 6) in accordance with the facility's policy and manufacturer's requirements in one of two inspected medication carts (Medication Cart Station 1 Cart 1). This deficient practice increased the risk that Residents 6 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to code a resident's correct discharge location on the Discharge Minimum Data Set (MDS, a standardized assessment and care screening tool) for one (Resident 140) of four residents reviewed under closed records (a resident that has been discharged from the facility). This deficient practice had the potential to delay care and services for the resident after discharge.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a discharge summary with a complete reconciliation of medications (a process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over-the-counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) was provided upon discharge to the residents or responsible party (RP) for three of three sampled residents (Resident 1, Resident 3, and Resident 4) by failing to document what post-discharge medications the residents were to take and were provided and the amount of medications provided. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Attendant 1 (CNA 1) was wearing personal protective equipment (PPE- specialized clothing or equipment worn for protection against infectious materials) while in a resident's room who was on contact isolation precautions (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) resulting in the potential spread of germs placing residents, staff, and visitors at risk to be infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's tissue box was placed to be used when needed for two of eight sampled residents (Resident 1 and Resident 3). This deficient practice had the potential to result in hindering the residents' independence to clean their face and maintain personal hygiene by using tissues.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a grievance filed by one of three sampled residents (Resident 1) was documented and filed in the facility grievance log. This deficient practice had the potential to affect the residents' quality of life and the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 3), who made an allegation of financial abuse. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 3.

Inspectors wroteBased on observation, interview and records review, the facility failed to remain free of pest when on 6/25/2024, a fly (small, winged insect) was observed in the kitchen and landed on top of a tuna container. This deficient practice placed a total of 118 of 129 residents at risk of food borne illnesses (disease contracted from eating contaminated food).

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 147) was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when: 1. Certified Nursing Assistant 2 (CNA 2) did not inform a licensed nurse (a Licensed Vocational Nurse [LVN] or Registered Nurse [RN]) of Resident 147's request for a snack on 4/14/2024 which would then require a licensed nurse to complete a Diet Order and Communication Form (DOCF- a form designed to ensure clear communication between residents, nurses and dietary staff that indicates dietary preferences and restrictions to promote safe food distribution) prior to providing food to Resident 147. 2. [...]

Inspectors wrote4.a. A review of Resident 51's admission Record indicated the facility admitted the resident on 7/30/2020 with diagnosis including arthritis (swelling, stiffness, and pain in the joints), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 51's MDS dated [DATE], indicated Resident 51 needs supervision and touch assistance with eating. A review of Resident 51's physician's order dated 4/25/2024, indicated an order for restorative nursing assistant (RNA- a program designed to ensure each resident maintains their physical and functional abilities) feeding program for breakfast and lunch for 30 days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure that two of six sampled residents' (Resident 96 and 103) low air loss mattress (LAL- a special mattress designed to distribute the resident's body weight over a broad service area to help prevent skin breakdown) was set to the correct setting. 2. Provide a resident who was at risk for developing pressure ulcers (a skin injury caused by constant pressure over a long period of time) with bilateral (both sides) heel protectors while in bed, as ordered by the physician, for one of 32 sampled residents (Resident 7). These deficient practices had the potential to cause further skin breakdown for these residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to: 1. Ensure thickened lemon-flavored water cartons (water that has a thickened texture for those who have swallowing problems) found in the dry-food storage area were not stored past their use-by date. This deficient practice had the potential to place seven out of 146 residents who were prescribed thickened liquids at risk for foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages). 2. Ensure a dented food can was not found stored with other food cans ready for consumption. 3. Ensure two canned foods of ravioli pasta found in the dry-food storage area were not stored past their use-by date. This deficient practice had the potential to place 134 out of 146 residents living in the facility at risk for foodborne illnesses.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate clinical records by failing to ensure one of one sampled resident (Resident 347) had compete documentation for their Toilet/Bladder/Bowel Task flow sheet. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 347.

Inspectors wrote2. A review of Resident 8's admission Record indicated the facility originally admitted the resident on 12/03/2021 with a diagnosis including pneumonia (an infection that inflames the air sacs in one or both lungs), sepsis (a life-threatening complication of an infection), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 2/21/2024, indicated Resident 8 needs set up and clean up assistance during meals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device that allows patients to request assistance from staff) was functioning for five of five sampled residents (Resident 33, Resident 98, Resident 346, Resident 117, and Resident 258). This deficient practice had the potential to cause a delay in the residents' care and for the residents' needs to remain unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) was obtained from a resident's responsible party (person, usually a family member who makes medical decisions for a resident) for one of five sampled residents (Resident 19) regarding the use of an antipsychotic (antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]). This deficient practice had the potential for the responsible party to not be informed on medication therapy decisions that may or may not affect a resident's health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received full visual privacy during a medication administration observation by failing to provide the resident with a privacy curtain (used to create private spaces for patients in healthcare facilities) that was long enough to cover the foot of his bed for one of 32 sampled residents (Resident 129). This deficient practice violated the resident's right to privacy.

Inspectors wroteBased on interview and record review, the facility failed to have one of one sampled resident (Resident 51) evaluated for Preadmission Screening and Resident Review (PASARR- an assessment to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level II. This deficient practice had the potential for Resident 51 to not receive specialized mental health services to manage the resident's behaviors.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for a resident's use of lorazepam (medication used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) for one of one sampled resident (Resident 96). This deficient practice had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of 32 sampled residents (Resident 131) whose primary and preferred language was not English. This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving appropriate care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident who was at risk for elopement (when a patient leaves a healthcare facility without authorization or discharge, and doing so can endanger their health or safety) had on a Wander Guard (a wander management system that consists of bracelets worn by residents, sensors the monitor doors, and a platform that sends real-time safety alerts), as ordered by the physician, for one of 32 sampled residents (Resident 66). 2. Ensure a resident who was at risk for falls had their pressure pad alarm (a sensor that detects changes in pressure when someone is on it) turned on while the resident was in bed for one of 32 sampled residents (Resident 66). This deficient practice had the potential to place the resident at increased risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to ensure that facility staff assessed the peripherally inserted central catheter (PICC line- type of catheter [tube] that is placed in a large vein that allows for medications to be administered intravenously [directly into the vein]) for one of one sampled resident (Resident 396) upon admission to the facility on 4/26/2024. This deficient practice had the potential to place Resident 396 at risk for sepsis (the body's extreme response to an infection. Sepsis is a life-threatening medical emergency from a central line-associated bloodstream infection [CLABSI- a serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line]).

Inspectors wroteBased on interview and record review, the facility failed to complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 80) investigated addressing the dialysis care area. This deficient practice placed Resident 80 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were posted daily 6/14/2024 as indicated in the facility's policy and procedure (P&P) on Direct Care Daily Staff Numbers. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard a discontinued vial of lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) for one of one sampled resident (Resident 96). This deficient practice had the potential to place the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications (medications with a high potential for abuse).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was started on an antibiotic (medication that fights bacterial infections), met the McGeer criteria (a set of surveillance criteria for identifying healthcare-associated infections [HAIs - infections that patients get while receiving health care at a facility]) prior to starting on the antibiotic, and that the physician was notified when the resident did not meet the McGeer criteria for one of 32 sampled residents (Resident 259). This deficient practice had the potential to result in the resident experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the antibiotic.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remain free of pest when on 5/2/2024, a cockroach (small insects that carry and spread infectious diseases) was observed in the facility hallway. This deficient practice placed a total of 22 out of 146 residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Discharge Minimum Data Set (MDS - a standardized assessment and care screening tool) was transmitted within 14 days after the completion date for one of 32 sampled residents (Resident 126). This deficient practice had the potential to delay care and services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 31 of 31 sampled residents (Resident 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31) who utilize the facility's dining room, were not prohibited (to not allow a resident to do something) from the group activity of communal dining (the practice of dining with others) when on 3/21/2024, the Director of Nursing (DON) closed the facility's dining room during the residents designated communal lunch time in order to celebrate the DON's birthday. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that one of two sampled residents (Resident 1), who exhibited an episode of suicidal ideation (thinking about or planning suicide [act of intentionally causing one's own death]) on 12/28/2024, was provided with the necessary behavioral health care and services as evidenced by: 1. Failing to conduct an Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their residents) meeting for Resident 1 when Resident 1 had a Change in Condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) related to suicidal ideation on 12/28/2024. 2. Failing to implement Resident 1's care plan related to suicidal ideation. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to provide the needed care and services that were resident-centered for one of three sampled residents (Resident 4), as evidenced by not: 1. Assessing Resident 4 ' s generalized condition upon admission on [DATE]. 2. Timely evaluating Resident 4 ' s neurological (deals with problems affecting the nervous system such as brain, spinal cord, and a complex network of nerves) condition after an unwitnessed fall on 10/11/2023. As a result, Resident 4 was placed at high risk of not identifying care needs on admission and prompt identification of complications from the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pressure pad alarm device (device that contain sensors that trigger an alarm or warning light when it detects a change in pressure when the resident is attempting to stand up) in bed was attached correctly and the landing mats (cushioned mats placed on the floor at bedside to decrease the impact on the floor in case of the fall) were placed on the floor in order to prevent fall and injury for one of three sampled residents (Resident 5). This deficient practice placed Resident 5 at risk of complications from a fall including fractures (break in the bones), bleeding, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multidose medications were labeled with an open date (when nursing staff writes the date a medication is opened for the first time) as evidenced by: 1. Registered Nurse 1 (RN 1) failing to label a bottle of normal saline (NS - a sterile solution made of salt and water) after opening it for one of three sampled residents (Resident 1). 2. RN 1 failing to label a tube of Triad cream (cream used for wound healing) for one of three sampled residents (Resident 2). These deficient practices increased the risk that Residents 1 and 2 could have received medication that had become ineffective due to improper labeling possibly leading to health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement proper infection control practices during wound care treatments as evidenced by: 1. Registered Nurse 1 (RN 1) using alcohol-based hand rub (a type of hand sanitizer [cleaner] that is alcohol-containing preparation [liquid, gel or foam] designed for hand hygiene [washing of hands]) to disinfect the scissors used during wound care for one of four sampled residents (Resident 1). 2. RN 1 failing to disinfect (to clean) the bedside table used during wound care treatments for three of four sampled residents (Residents 1, 2, and 3). These deficient practices had the potential to spread bacteria from resident to resident and cause infections in the wounds being treated for Residents 1, 2 and 3.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy by failing to ensure a grievance was documented per facility policy for one of three sampled residents (Resident 1). This deficient practice had the potential to violate residents' rights to have grievances addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) was provided restorative (having the ability to restore health, strength, or a feeling of well-being) services to reduce further contractures (a permanent shortening of muscle or scar tissue producing deformity) of both elbows and left hand. This deficient practice placed Resident 3 at increased risk for worsening and further development of contractures.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident ' s rights to be free from physical abuse (any act of hurting or injuring a resident on purpose) by Resident 2 for one of seven sampled residents (Resident 1). This deficient practice resulted in Resident 1 being hit on the right upper arm and leg by Resident 2 while under the care of the facility and had the potential to cause emotion harm which could result in a feeling of low self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident ' s call light was answered timely for one of seven sampled residents (Resident 2). On 8/25/2023, Resident 2 ' s call light was left unanswered for 14 minutes from 9:39 a.m. through 9:53 a.m. This deficient practice placed the resident at risk of inability to summon health care workers as needed to receive the assistance that may include urgent care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 3) was provided the necessary treatment and services to promote healing of pressure ulcer (PU - injury to skin and underlying tissue resulting from prolonged pressure on the skin) when staff placed multiple layers of linen over the residents ' low air loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts). This deficient practice placed the resident at increased risk for worsening and further development of PU and delayed wound healing.

Inspectors wroteBased on interview and record review, the facility failed to monitor and obtain one of eight sampled residents (Resident 3) weight for the month of 2/2023 and 7/2023. This deficient practice had the potential to result in Resident 3 ' s unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled resident ' s (Resident 3) Minimum Data Set (MDS- a standardized assessment and care-screening tool) accurately reflected the resident ' s functional limitation in range of motion (FLIROM - limited ability to move a joint that interferes with daily functioning) for upper extremities (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). This deficient practice had the potential to negatively affect the resident ' s plan of care and delivery of necessary care and services.