Woods Health Services

Inspectors wroteBased on interview and record review the facility failed to provide documentation regarding advance directives (AD-a legal document explaining a resident's health care wishes if he or she cannot speak for themselves) for four of four sampled residents (Residents 8, 20, 21, & 35) when:1. Resident 8 and Resident 21 were not provided with information regarding ADs.2. Facility failed to ensure a copy of Resident 20's AD was in Resident 20's medical record when Resident 20's medical records indicated Resident 20 had a POA (Power of Attorney - a legal document that allows someone else to act on your behalf to manage your financial, legal, or medical affairs).3. Resident 35's AD signature page was not included in Resident 35's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for three of three sampled residents (Residents 6, 32, & 42) when:1. Resident 6's lack of bowel movement (BM) was not addressed in a timely manner when Resident 6 was at risk for constipation and did not have a BM from 5/13/2026 to 5/19/2026.2. The facility failed to ensure their process for over the counter (OTC - medicines you can get without a prescription) product self-administration (the process where patients manage and take their own medications) was followed for Resident 32 when on 5/19/2026 Resident 32 had multiple non-legend (drugs that can be purchased OTC without a prescription) products at Resident 32's bedside without a self-administration assessment or a physician's order.3. Resident 42's right arm sling was not positioned properly following a shoulder injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 17 and Received 20) received proper respiratory (relating to breathing) care by failing to date or properly date Resident 17 and Resident 20's nasal cannula (NC - a small plastic tube that fits into the person's nostrils and used to provide supplemental oxygen [02 - a colorless, odorless, tasteless gas essential for living) tubing. This deficient practice could potentially result in the facility using old or expired NC tubing leading to bacterial and mold growth and skin irritation to Resident 17 and Resident 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled nursing staff (Certified Nursing Assistant [CNA] 3), had the appropriate competencies and skills sets necessary to care for the residents' (in general) needs when the facility failed to ensure CNA 3 met the clinical skill (the practical, hands-on tasks and critical-thinking abilities nurses use to deliver patient care) of reporting unusual occurrences. This deficient practice had the potential to result in compromised resident safety and physical declines to the residents under CNA 3's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was free of five percent or greater medication error rate. The facility had two total medication errors in 25 opportunities for errors during medication pass (process through which medication is administered [the act of giving a treatment, such as a drug, to a patient]) for one of two sampled residents (Resident 35) which yielded an eight percent total error rate when: a. Licensed Vocational Nurse (LVN) 2 prepared and attempted to administer the wrong dose of Fluoxetine (an anti-depressant [prescribed medication used to treat depression - a mood disorder that causes a persistent feeling of sadness and loss of interest]) to Resident 35. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when the following was observed:1. [NAME] 1 (CK 1) and the dietary manager (DM) were not wearing beard covers while preparing food for the residents of the facility.2. On 5/21/2026, two of three sampled sanitizing solution buckets (SB) did not have the correct concentration required to effectively kill bacteria (microscopic single-celled organisms some can make people sick) and organisms from kitchen surfaces as indicated in the facility's policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to: a. Ensure two of five sampled residents' (Resident 55 and Resident 20) nasal cannula (N/C - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen [a colorless, odorless, and tasteless gas essential for life]) tubing was not on the floor b. Label a personal care item stored inside the shared restroom for two of two sampled residents (Resident 57 and Resident 26). [...]

Inspectors wroteBased on interview and record review, the facility failed to submit and transmit the discharge Minimum Data Set (MDS, a standardized assessment and care-screening tool) assessment within 14 days after the MDS completion for one of one sampled resident (Resident 2) as indicated in the Centers for Medicare & Medicaid Services (CMS, is a federal agency that administers major public health insurance programs and sets the regulatory standards for the United States healthcare system) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manual. This deficient practice resulted in a late completion and transmission of Resident 2's MDS assessment to CMS's Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan (CP) was developed for one of one sampled resident (Resident 40) in accordance with the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered. This failure had the potential to result in unmet individualized needs for Resident 40 and the potential to affect Resident 40's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified from the Monthly Drug Regimen Review (MDRR), reported by the facility's pharmacist were acted upon for one of five sampled residents (Resident 5). These deficient practices had the potential to result in unnecessary medication administration and physical harm to Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete for one of three sampled residents' (Resident 4). Resident 4's Inventory of Personal Effects (IPE) form was not signed or dated to indicate Resident 4's personal belongings were picked up by Resident 4's family when Resident 4 was discharged from the facility. This failure resulted in inaccuracy of Resident 4's IPE after Resident 4 left the facility.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the physician of a change in condition for one (1) of three (3) sampled residents (Resident 1) when Resident 1's new onset buttocks pain following a fall on 4/23/2026 was not communicated to Resident 1's primary physician. This deficient practice had the potential to delay further assessment, timely diagnostic evaluation, and timely interventions related to the resident's change in condition and possible injury. [...]

Inspectors wroteBased on interview and record review the facility failed to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and manual or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) to one of three sampled residents (Resident 3) in accordance with the facility's Policy and Procedure (P&P) titled Emergency Procedure- Cardiopulmonary Resuscitation, dated [DATE], when: 1. Rescue breaths were not provided to Resident 3 on [DATE] at 12:35 PM. 2. An artificial manual breathing unit (Ambu bag, a handheld medical device used to manually force air or oxygen into a person's lungs) and a non-rebreather oxygen mask (a medical device used in emergencies to deliver high concentrations of oxygen) were available for use in the facility's emergency cart on [DATE] 12:35 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services to one (1) of three (3) sampled residents (Resident 1) when:A. Licensed Nurses failed to assess and accurately document Resident 1's pain status following a fall on 4/23/2026. B. Resident 1's new onset buttocks pain following a fall on 4/23/2026 was not communicated to Resident 1's primary physician. These deficient practices had the potential to result in inaccurate pain assessment, delayed recognition of worsening conditions or injury, and ineffective pain management interventions for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate safety precautions during activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care for one (1) of three (3) sampled residents (Resident 1) by failing to ensure:A. A safe environment during post-shower care on 4/23/2026 by allowing Resident 1 to stand while the floor remained wet. B. Safe ADL care practices were implemented during post-shower care on 4/23/2026 by allowing Resident 1 to stand while clothing remained positioned at the resident's knees, creating increased instability and fall risk. C. Two (2) staff assisted Resident 1 to get up and stand from the shower chair on 4/23/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards, as evidenced by: 1. Facility did not ensue Certified Nursing Assistants (CNAs) maintained a current cardiopulmonary resuscitation ([CPR] an emergency procedure used when a person's breathing or heartbeat stops) certification while working at the facility. 2. Facility did not ensure CNAs were evaluated annually for patient care competencies and skills. 3. Facility did not ensure licensed nurses had a complete competency and evaluation checklist on file. 4. Facility did not ensure Registered Nurse (RN1) was evaluated by competent licensed nurse. 5. Facility did not ensure licensed nurses were competent during a resident emergency. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was properly assessed and monitored upon experiencing a change in condition when:1. Resident 1's oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) was not reassessed after oxygen was administered to Resident 1 on [DATE] after Resident 1 was found unresponsive with an O2 sat of 89% (normal O2 sat level for most healthy adults is between 95% and 100%).2. Resident 1's blood pressure (BP) and respiratory/breathing rate (RR) were not assessed on [DATE] when Resident 1 was found unresponsive at 11 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the comprehensive person-centered care plan for one of three sampled residents (Residents 1) when Certified Nurse Assistant (CNA) 1 failed to use 2 staff persons while transferring (moving a resident from one flat surface to another) Resident 1 with an EZ Stand (a transfer-assist device) according to Resident 1's Care Plan Report (CPR), undated. This failure had the potential for Resident 1 to fall and sustain injuries while being transferred. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an annual performance review for four of four sampled Certified Nursing Assistants (CNA). This failure had the potential to result in the CNA's giving the residents improper care, making clinical errors, and causing resident injury.

Inspectors wroteBased on interview and record review, the facility staff failed to inform one of one sampled resident's (Resident 1) doctor of Resident 1's low blood pressure (BP - the force of blood pushing against the artery walls as the heart pumps around the body) reading on 12/4/2025 when Resident 1 was admitted to the facility. This deficient practice had the potential to lead to further complications such as dizziness, confusion, and physical injury to Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to implement interventions to reduce the risk for falls for one of three sampled residents (Resident 1), who was at high risk for falls, when Resident 1 was admitted to the facility on [DATE] with low blood pressure (a condition in which the force of blood pushing against the artery walls is too low). This deficient practice potentially led Resident 1 to slide off Resident 1's bed onto the floor on 12/4/2025 while attempting to stand to use the urinal. This deficient practice had the potential to result in injury and a physical decline to Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its own Unusual Occurrence Reporting policy, which requires that unexpected resident deaths be reported to the State Licensing Agency within 24 hours. This failure resulted in a delay of state regulatory notification, which has the potential to delay timely oversight, review, and investigation of resident safety incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment for a left first toe fracture (break in bone) per physician's orders. This deficiency had the potential for Resident 1's injury to get worse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received wound (an injury to living tissue caused by a cut) care and treatment in accordance with the facility's Policies and Procedures (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, when: a. Registered Nurse (RN) 1 failed to conduct a complete wound assessment (a thorough examination of both the wound itself and the resident's overall health to understand the wound's status, identify any factors hindering healing, and develop an effective treatment plan) and document Resident 1's left hip surgical wound (a cut through the skin made during surgery [a procedure to remove or repair a part of the body]) upon admission to the facility on 2/18/2025. b. RN 1 failed to obtain a treatment order for Resident 1's left hip surgical wound upon admission on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled resident (Resident 1) when: a. Registered Nurse (RN) 1 failed to document Resident 1's left hip wound upon admission to the facility on 2/18/2025. b. Facility staff (in general) failed to document the description of Resident 1's left hip wound on 3/19/2025, 3/26/2025, 4/9/2025, and 4/16/2025. These failures resulted in Resident 1's medical record containing inaccurate and incomplete information. (Cross Reference F656 and F684)

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled resident (Residents 1) by failing to ensure Resident 1's care plan's interventions included a treatment order to cover Resident 1's left hip wound. This failure had the potential result in unmet individualized needs for Resident 1 and the potential to affect the resident's physical and psychosocial well-being. (Cross Reference F684 and F842)

Inspectors wroteBased on interview and record review, the facility failed to promote the resident/responsible party's right to be informed of and participate in treatment for one of five (Resident 29) sampled residents by failing to obtain a consent and inform Resident 29's responsible party in advance of the risks and benefits of a psychoactive (medications that affect the mind or behavior) medication, Seroquel (a medication used to treat symptoms of psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]). This failure violated the responsible party's right to make an informed decision on behalf of Resident 29 regarding the use of a psychoactive medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified from the Monthly Drug Regimen Review (MDRR), reported by the facility's pharmacist were acted upon for one of five sampled residents (Resident 13) by failing to: a. Ensure action was taken for the use of GI meds Famotidine and pantoprazole for January 2025 b. Ensure Resident 13's physician was informed to reconsider the use of simvastatin (medication used to treat fat in the blood) for February 2025. c. Ensure Resident 13's physician was informed to consider a gradual dose reduction for antipsychotic medication (medication to treat psychosis [loss of touch with reality] for March 25025, These deficient practices had the potential to result in unnecessary medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices by failing to: a. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed and Personal Protective Equipment (PPE, gown, gloves, mask and face shield) were worn while providing care for Resident 47. b. Ensure Resident 8's nasal cannula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears) did not touch the floor. c. Ensure Resident 47's NC did not touch the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light was within reach for one of one sampled resident (Resident 31) and failed to ensure a call light was answered timely for one of one sampled resident (Resident 30). This deficient practice had the potential to result in a delay in treatment and/or result in unmet needs for Resident 31 and Resident 30. Additional the deficient practice had the potential to result in harm to Resident 30.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a standardized assessment and screening tool) related to anticoagulant (medicine that help prevent blood clots) use for one (1) of 1 sampled resident (Resident 26). This deficient practice had the potential to negatively affect Resident 26's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a resident assessment tool) accurately reflected one of one sampled resident's (Resident 47) hospice (interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating or reducing suffering among people with serious and often terminal illnesses expected to live six months or less, end of life) status. This deficient practice had the potential to result in unsuitable treatment and unmet needs to Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications, their purpose, and potential side effects were explained prior to administration for one (1) of two sampled residents (Resident 19). This failure posed a risk of adverse drug reactions, decreased resident understanding and compliance, and a violation of resident rights to informed consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one of one sampled residents (Resident 8) by failing to: a. Ensure Resident 8 received the correct amount of oxygen [colorless, odorless gas] ordered via nasal cannula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears). This deficient practice resulted in incorrect oxygen administration to Resident 8 the the potential for a physical decline to Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a physician order for floor mats to be placed on both sides of the bed to prevent injury in the event of a fall for one (1) of three sampled residents (Resident 36). This failure had the potential to result in a preventable injury, such as fractures or head trauma, due to an unprotected fall from bed, compromising resident safety and care standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual nursing hours for all shifts from 4/3/2025 to 4/4/2025 and failed to ensure the hours were posted in a prominent place to be readily accessible for residents and visitors. This failure had the potential to result in the residents and visitors not knowing whether there was sufficient staff to provide quality care to the residents and resulted in nurse staffing information being inaccessible to visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 13) who was on a psychotropic medication (medications that affect the mind, emotions, and behavior), Seroquel (used to treat certain mental/mood conditions) received a gradual dose reduction as indicated by the facility's pharmacist recommendation and the facility policy. This deficient practice had the potential to result in the resident taking psychotropic medication unnecessarily and be at risk for further harm/injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to proper food storage and ensure sanitary conditions were followed by failing to: A. Ensure food past it's use-by date was not stored in one of one walk-in refrigerator (Refrigerator 1) observed in the kitchen. B. Ensure staff were completing the sanitation bucket log, ice machine log, and dish machine log daily. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate discharge disposition medical record documentation for one of one sample resident (Resident 50). This deficiency resulted in incomplete and potentially misleading information regarding the Resident 50's discharge status.

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate and monitor for signs and symptoms of Respiratory Syncytial Virus (RSV - is a common respiratory virus that usually causes mild, cold-like symptoms that affects infants and older adults who are more likely to develop severe RSV and need hospitalization) among healthcare personnel/healthcare workers after these healthcare workers exposed to two of two sampled residents (Residents 1 and 2) who tested positive for RSV. These deficient practices had the potential to spread RSV to other residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention and control program for 2 of 4 sampled residents (Residents 1 and 2) by failing to ensure hand hygiene was performed during meal pass at lunch between Resident 1 and Resident 2. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 1 and 2. Findings During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/27/2024, and re-admitted the resident on 12/12/2024, with diagnoses including left femur (thigh bone) fracture, gastrointestinal hemorrhage (any bleeding that occurs in the digestive tract, from the mouth to the anus), and muscle wasting and atrophy (loss of muscle tissue). [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the infection monitoring form during an influenza outbreak for one of four sampled residents (Resident 3). This deficient practice had the potential for Resident 3 to not have an accurate assessment, progression, or regression of the delivery of care services.

Inspectors wroteBased on interview and record review, the facility failed to follow its policies and procedures (P&P) titled, Falls Management Program, and Care Plans, Comprehensive Person-Centered, by failing to revise the care plan and implement new interventions after multiple falls for two of three sampled residents (Resident 1 and 2). This deficient practice had the potential to place Residents 1 and 2 at risk for further falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Charting and Documentation, to have complete documentation for one of three sampled residents (Resident 1). This deficient practice had the potential for lack of communication between the facility staff regarding Resident 1's condition and could result in inconsistencies of care.

Inspectors wroteBased on interview and record review, the facility failed to report a communicable disease (an illness that can spread from one person to another, or from an animal to a person, or from a surface or food) to the California Department of Public Health (CDPH) for one of three sampled residents (Resident 1) when Resident 1 tested positive for Hepatitis A virus (a highly contagious virus transmitted through ingestion of contaminated food and water or through direct contact with an infectious person). This deficient practice had the potential for a communicable disease to spread and not be properly and timely investigated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices to reduce and/or prevent the spread of Covid-19 (Coronavirus, a highly contagious respiratory disease caused by SARS-CoV-2 virus that spreads from person to person and can cause mild to severe respiratory illness) in accordance with the facility's policies and procedures (P&Ps) when: a. One of one housekeeper (Housekeeper, HK) entered a Covid-19 isolation room without the required face shield, or goggles as indicated on the sign posted outside Resident 1's room. b. Three of three tumbler cups belonging to facility staff were left on the handrail in the red zone (a cohorting [grouping patients infected or colonized with the same infectious agent] for residents who tested positive for Covid-19). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer the call lights in a timely manner for seven of 16 sampled residents (Residents 2, 15, 30, 31, 148, 149, and 150). This failure resulted in Residents 2, 15, 30, 31, 148, 149, and 150 feel frustrated and had the potential for the residents to experience a decline in psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident-centered comprehensive care plans (CP, provides direction on the type of nursing care an individual needs) for three of three sampled residents (Resident 16, 25 and 11) were developed in accordance with the facility's policy and procedure (P&P). a. For Resident 16, the facility failed to develop a CP to address the use of Depakote Sprinkles medication (medication used to treat mental/ mood conditions). b. For Resident 25, the facility failed to individualize the CP related to Resident 25's nutritional weight goals and interventions related to difficulty chewing. c. For Resident 11, the CP related to risk for altered fluid balance did not have measurable objectives and timeframe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing resulting in toileting and/or incontinence care were not being provided in a timely manner for seven of 16 sampled residents (Residents 2, 15, 30, 31, 148, 149, and 150). This failure had the potential to result in Residents 2, 15, 30, 31, 148, 149, and 150 to experience skin breakdown and/or placing the residents at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F550)

Inspectors wroteBased on observation, interview and record review, the facility failed to follow safe and proper food storage and preparation practices in one of one facility kitchen, in accordance with professional standards for food service safety and the facility's policies and procedures (P&P) by failing to ensure: a. Food items were labeled/dated in the kitchen. b. Cold foods were held at 41 degrees Fahrenheit (F, a unit of measurement used to measure temperature) or lower. These failures had the potential for food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standard infection control practices in accordance with the facility's Policies and Procedures (P&P) by failing to: a. Safely and hygienically store personal toiletries and belongings for two of two sampled residents (Residents 9 and 98) b. Establish a surveillance plan to monitor or track infections in the facility in accordance with the facility's policy and procedure titled Infection Prevention and Control Program. These failures had the potential to result in cross contamination and/or spread of infection to the residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) was within reach for one of one sampled resident (Resident 28), as indicated in Resident 28's care plans (CP-provides direction on the type of care an individual needs) titled Risk for Falls, The Resident Had Communication Problem and Resident has anxiety manifested by screaming and yelling daily for help with her stuff animals. This failure had the potential to result in Resident 28's needs not met in a timely manner and/or Resident 28 to experience harm if Resident 28 was unable to alert staff during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 9) had directions/instructions regarding treatment requests and/or wishes in the event of a medical emergency (any serious illness or condition that poses an immediate risk ) as indicated in the facility's Policy and Procedure (P&P) and Resident 9's care plan (CP- provides direction on the type of care an individual needs) titled Resident Request Code status of Full Code (all treatment provided). This failure had the potential for Resident 9 to receive inappropriate or medically unnecessary care, treatment and/or services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident's (Resident 35) Minimum Data Set (MDS, a standardized assessment and care screening tool) was completed accurately. This failure could potentially result in Resident 35 receiving inappropriate care and services based on Resident 35's preferences and goals of care, functional and health status, and strengths and needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 40) was free of accident (any unexpected or unintentional incident) hazards by failing to maintain Resident 40's bed in a low position. Resident 40 had multiple history of falls (unintentionally coming to rest on the ground, floor, or other lower level). This deficient practice placed Resident 40 at risk for further falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's order to check the colostomy site ever shift to make sure it was not leaking and change the leaky colostomy bag in a timely manner for one of one sampled resident (Resident 5), who required colostomy (surgery to create an opening called a stoma. The opening creates a passage from the large intestine to the outside of your body) care and services. These failures had the potential for Resident 5's emotional well-being to be affected and had the potential to develop excoriation/breakdown to the skin surrounding the ostomy (or stoma, an artificial opening in the body, created during an operation such as a colostomy or ileostomy).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 10), received oxygen (O2 [a colorless, odorless, tasteless gas essential for living]) therapy consistent with professional standards of practice and in accordance with the physician's order. This failure resulted in Resident 10 to receive inaccurate oxygen supply and could potentially compromise Resident 10's medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents was free from unnecessary psychotropic (medicines that alter chemical levels in the brain which impact mood and behavior) medication (Resident 30). Resident 30's order for Lorazepam (medication to treat anxiety [an unpleasant state of inner turmoil and fear]) did not have an end date within 14 days from the time it was ordered. This failure had the potential for Resident 30 to receive unnecessary psychotropic medication that could result in adverse consequences for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one facility's Infection Preventionist (IP- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) completed a specialized training in infection prevention and control as indicated in the facility's job description of the Infection Preventionist. This failure had the potential for lack of oversight of the facility's infection control practices by the IP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) who had a history of falls by failing to implement the physician (MD) order dated 1/7/2024 to place bilateral floor mats (a cushioned pad placed to absorb the force when a resident falls) on each side of the bed and a silent bed/chair alarm (a sensor pad device placed under a resident's bottom that triggers an alarm when it detected a change in pressure and was used as an early alert that a resident was trying to get out of bed or chair) for Resident 1. These failures resulted in Resident 1 sustaining a fall resulting in a fracture (partial or complete break in the bone) of the right femoral neck of the hip (hip fracture of the thigh bone below the ball of the ball-and-socket hip joint). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nursing services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of three sampled residents (Resident 1), who had a history of multiple falls, by failing to: Ensure Resident 1's silent bed alarm system (an assistive electronic device that makes alerts/sounds to warn caregivers when the resident tries to get up from the bed while keeping the patient's/resident's environment free of noise/alarm sounds) was plugged into the electrical outlet and was functioning on 11/24/23. As a result, on 11/24/23, Resident 1 got up from Resident 1's bed unnoticed/unaware by staff (in general), fell from Resident 1's bed and sustained pelvis (ring of bones located between the spine and the legs) fractures (broken bones). [...]