York Healthcare & Wellness Centre

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its policy and procedure titled, Resident Rights by not honoring Resident 1's right to an overnight out-on-pass (OOP, a resident is temporarily permitted to leave a healthcare facility for a short, approved period of time) request for 7/7/2026 and 7/8/2026 to grieve the loss of a family member and attend the funeral and burial. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident centered care plan for one of three sampled residents (Resident 1) who sustained a fall while out of the facility during an out on pass (OOP an admitted patient has official, temporary permission from their doctor to leave a hospital or care facility for a short period) on 11/21/2025, and failed to ensure an Interdisciplinary Team (IDT) meeting was held to identify and investigate the reason for Resident 1's fall, in order to provide adequate care and services to Resident 1. This deficient practice resulted in Resident 1 not being assessed appropriately after sustaining a fall on 11/21/2025 while out of the facility and prevented Resident 1 from being permitted to obtain an OOP for two days, 7/7/2026 to 7/8/2026 to attend a funeral.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain safe food storage by keeping multiple expired food items (use-by date) in the dry storage and the refrigerator. The deficient practices increased the risk of residents being served unsafe or spoiled food. During a concurrent observation and interview on 7/21/2026 at 4:30 PM with the Dietary Supervisor (DS), the following items were observed in the dry storage area and the refrigerator:Four bags of assorted citrus Jello's labeled with a use by date of 7/10/2026 in the storage room. One bottle of rice vinegar labeled with an opened date of 2/12/2026 and with the manufacture use by date of 7/9/2026 in the storage room. One bottle of rice vinegar labeled with an opened date of 5/15/2026 and with use by date of 7/15/2026 in the storage room. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program to ensure the environment was free of pests (including flies, gnats, rodents, and other insects) by failing to: Ensure the kitchen exterior door was kept always closed and equipped with an intact door sweep to prevent pest intrusion into the kitchen. 2. Ensure residents' meal trays were free of gnats. These deficient practices had potential for pests to enter the food service area, leading to food contamination, spoilage, and increased risk of foodborne illness. As a result, residents were at increased risk of losing their appetite, refusing meals, and experiencing emotional distress when observing pests near their food.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three certified nurse assistants (CNA 1) maintained a valid certification while providing resident care. CNA 1's certification expired on [DATE], and the facility did not identify the expired status until [DATE]. As a result, CNA 1 provided resident care for 2 years, 6 months, and 4 days without a valid CNA certificate. This deficient practice had the potential to place residents at risk for harm, including inadequate care, neglect, and possible abuse due to the CNA 1 providing care without a valid certification.

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedure titled, Abuse Prevention and Management for one of three sampled residents (Resident 1) by, Failing to report to the State Agency (SA where state law provides for jurisdiction in long-term care facilities), ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local enforcement within 2 hours after Resident 1 reported an allegation of physical abuse to the facility. 2. Failing to thoroughly investigate, protect and prevent the possibilities of further abuse happening to Resident 1 and other residents in the facility. These deficient practices lead to Resident 1 feeling unsafe, frustrated for not being taken seriously. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and temperature for three (3) of 3 sampled residents (Resident 9, 77 and 78) in accordance with the facility's policy and procedure titled Food Temperatures These failures had the potential to result in decreased meal consumption and negatively affect the health and well-being of residents receiving meals in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in accordance with the facility's policies and procedures, titled Food Storage and Handling , Refrigerated Storage Guide, Produce Storage Guideline, and Ice Machine& Ice Storage Chest to prevent the outbreak of foodborne illness (an infection or irritation of the gastrointestinal tract caused by consuming food or beverages contaminated with bacteria, viruses, parasites, or chemical toxins) for 96 of 99 residents receiving food from the kitchen . The facility failed to: Discard 9 cucumbers beyond labeled use-by date 5/16/2026 stored in the refrigerator. Label and store one case of frozen boneless chicken thighs that indicates Received date and use-by-date. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the heating, ventilation, and air conditioning (HVAC) system was properly maintained to provide a safe and comfortable environment for 97 residents. The HVAC unit servicing the conference room malfunctioned and emitted a burnt plastic odor and white smoke into the facility. The malfunctioning HVAC unit had the potential to adversely affect resident health and safety by exposing residents to smoke and burnt odors, causing respiratory discomfort, anxiety, and the need for emergency response measures. During a review of the facility Maintenance Log titled Checking HVAC and Coils, changing filters dated 1/2026 to 5/2026, indicated that routine inspections that were documented for HVAC Units 1 through 9 were documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a comprehensive care plan for one out of four sampled residents (Resident 4) when the Resident 4's foley catheter (a thin hollow tube that is inserted through the opening of the urinary tract into a person's bladder and is used to drain the bladder into an external collection bag) was changed as a result of a change in condition due to significantly cloudy urine in accordance with the facility's policy and procedure titled Person-Centered Care Planning and Change in Condition. This deficient practice had the potential for Resident 4 to be at risk for complications related to the use of foley catheter such as infection and injury due to accidental removal of the catheter if notFindings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the comprehensive care plan for one out of three sample residents (Resident 39) to address the interventions and goals needed for Resident 39's was ordered to receive prednisone (a medication that suppresses the immune system and reduce inflammation) in accordance with policy and procedure titled Person-Centered Care Planning and Adverse Drug Reactions. This deficient practice placed Resident 39 at risk of not to be monitored and receive immediate care for the potential side effects of the medication, such as the risk of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good oral hygiene as indicated in the facility's policy and procedure titled 'Oral Care. This deficient practice had the potential to result in discomfort, pain, impaired oral health, and a decline in overall well- being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident receives care consistent with professional standard of practice to prevent pressure ulcers (a skin breakdown due to unrelieved pressure and friction to the skin) for one of one sampled resident (Resident 22), who was a high risk to develop pressure ulcer, with a waffle mattress (mattress to prevent pressure ulcer) overlay setting at 140 (firmness setting of the mattress 80 [soft] - 280 [firm] ) as per physicians order. This deficient practice had the potential to result in development of pressure ulcer and/or skin breakdown, which could negatively affect Resident 22's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and hazard free environment in accordance with the facility's policy and procedure titled Resident Safety and Maintenance Service for one of three sampled residents (Resident 1), who was observed lying in bed under his overhead light fixture with plastic cover sagging and not properly secured. This deficient practice had the potential for the light fixture plastic cover to fall on to Resident 1 and cause injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 34 and 4) received appropriate treatment and services for urinary care in accordance with the professional standard of practice and facility's policy and procedures titled Indwelling Catheter, Guideline for Prevention of Catheter-Associated Urinary Tract Infection (2009) (CAUTI, a catheter associated UTI (an infection of the urinary tract that includes urethra, ureters, bladder and kidneys resulting when microorganism gets into the urine and travels to the urinary tract) and Suprapubic Catheter Re-insertion and Management. The facility failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to insure one out of eight sampled residents (Resident 2) offered and received the sufficient fluid intake to maintain proper hydration as recommended by the Registered Dietitian (RD) baseline daily fluid intake (calculated fluid a resident should consume each day) to ensure proper hydration. This deficient practice had the potential to result in Resident 2's continued dehydration (fluid deficit), impaired oral health, kidney damage, urinary tract infections, hospitalizations, and could result in a decline in the resident's overall condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two out of three medication rooms (MR), did not contain medications that were past the discard by date in accordance with the policy MR 2 contained two bags of Ertapenem (an antibiotic, medication that is used to treat infections) that were past the discard date. MR 3 contained one syringe of Enbrel (a medication used to reduce inflammation and swelling) that was past the discard date. This deficient practice had the potential for residents to be administered expired medications, which could lack the intended efficacy to treat the residents' diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of documentation for two out of four sampled residents (Resident 9 and Resident 94) who were observed during medication administration in accordance with the facility's policy and procedures titled Medication Administration- General Guidelines, by failing to ensure: 1. Licensed Vocational Nurse (LVN) 2 did not document the administration of Resident 94's meclizine (a medication used to treat dizziness) prior to the administration of the medication. 2. LVN 1 did not document the administration of Resident 9's acetaminophen (a medication used to control pain) prior to the administration of the medication. This deficient practice had the potential to cause inaccuracies in the residents' records, which could cause the misadministration of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's policy and procedure for infection control by failing to ensure a safe and sanitary environment to prevent transmission of diseases and infections for one of three sampled resident (Resident 8), who was observed on 5/20/2026 with a suction cannister (a medical receptacle used with suction machines to collect bodily fluids-such as mucus, and secretion) dated 5/18/2026 half-filled with cloudy secretions. This deficient practice can result in the suction cannister to harbor bacteria and/or virus (microscopic germs that can invade the body and cause infections) which potentially can get Resident 8 and negatively affect her quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 1), who was at risk for fall due to poor safety awareness and history of repeated falls was provided care and services to prevent recurrent falls in accordance with the facility's policy and procedures (P&P). The facility failed to: 1. Ensure a fall assessment and reassessment was conducted to identify the risk factors and cause of each fall, in accordance with the facility ' s Fall Management Program. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light (consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the patient's room) was within reach for Three out of eight sampled residents (Residents 66, 83, and 54). This deficient practice has the potential to delay care and services to the residents and preventing a timely response to care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection control policy of two out of two sampled residents (Resident 25 and Resident 29) by failing to: 1. Ensure Resident 25, who had a wound infection and used a peripheral inserted central catheter (PICC a long, thin tube that's inserted through a vein in the arm and passed through the larger veins near the heart) to receive antibiotics (medicines that fight bacterial infections in people) was provided care using enhanced barrier precaution (EBP) (taking extra steps to prevent the spread of serious infections, like using gowns and gloves) by Certified Nurse Assistant (CNA) 4 who failed to wear a gown. 2. Ensure a used glove was disposed of properly after each use and not placed on Resident 29 ' s blanket while Resident 29 laid in bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for two of two sampled residents (Residents 89 and 32) by failing to ensure: Resident 89 was provided with a wall clock in the room, and Resident 32 ' s bedside table was in functional and working condition. These deficient practices had the potential to create an uncomfortable environment leading to Resident 89 verbalizing feelings of frustration and Resident 32 ' s personal items to be exposed.

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of three sampled residents (Resident 94) Speech Therapy (ST, helped people who had trouble with speaking, understanding language, or swallowing). This deficient practice had the potential for a lack of individualized care and to affect the quality of services provided to Resident 94.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan were revised for two of two sampled residents (Resident 1 and Resident 94) that included resident-specific interventions. This deficient practice had the potential to delay care and services that were specific to the residents ' needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the insulin order to manage the diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing ) of one of one sampled residents (Resident 79) was followed when Resident 79 ' s blood sugar was tested above 300 mg/dL, in accordance with the physician ' s order to notify the physician of the results. This deficient practice had the potential for facility staff to mismanage the Resident 79 ' s diabetes mellitus.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 84) who had a Foley catheter (a thin, flexible catheter used especially to drain urine from the bladder), received appropriate care when Resident 84 ' s Foley catheter was nonfunctioning and leaking. This deficient practice had the potential to result in an increased risk for urinary tract infection (UTI- an infection in any part of the urinary system), increased pain and discomfort for Resident 84.

Inspectors wroteBased on interview and record review the facility failed to ensure one of six sampled residents (Resident 7) who received dialysis (a life-sustaining treatment for people whose kidneys were not functioning properly, replacing their filtering function) had a post-dialysis weight documented on 5/3/2025 and 5/10/2025. This deficient practice had the potential for unidentified complications after dialysis such as fluid shifts or significant weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 52), who was receiving Apixaban (anticoagulant medication used for the treatment of blood clots) was adequately monitored for signs and symptoms of bleeding. This deficient practice had the potential for Resident 52 to not be adequately monitored leading to the worsening of Resident 52 ' s health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the room space were at a minimum of 80 square feet (Sq. Ft.- a unit of measurement) for two out of 42 residents rooms (Rooms A & B). The two resident rooms consisted of two beds each room. Room A was occupied by Resident 65. This deficient practice had the potential to negatively impact the quality-of-care and the ability of the nursing care to safely provide care and privacy to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), having a history of dementia ( a Condition of brain that makes it hard for a person to make decisions , and think clearly), requiring 1:1 supervision (one staff member is assigned to stay with and closely monitor one specific person at all times) for safety was not left unsupervised by Licensed Vocational Nurse (LVN) 2. This deficient practice resulted in Resident 1 sustaining a fall on 3/13/2025, requiring transfer to the acute hospital for evaluation and had the potential for serious physical injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), to be readmitted back to the facility on the first available bed, in accordance with the facility ' s policy and procedure titled Bed-Holds and Return, and the California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities. Resident 1, was transferred from the Skilled Nursing Facility (SNF 1) to GACH 1 on 2/04/2025 for further evaluation of Candida Auris (CRS) and was medically stable to be discharged back to the SNF 1 on 2/05/2025 but SNF 1 refused to readmit Resident 1 back to the facility. Resident 1 had to stay in the GACH for additional seven (7) days (from 2/05/2025 to 2/11/2025) and was discharged home on 2/12/2025 with home health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent one of four sampled residents (Resident 2) from developing pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) by not providing the necessary treatment and services to prevent the formation of and promote healing of pressure injury in accordance with the facility's policy and procedure and physician's order. This failure resulted in Resident 2 developing Deep Tissue Injuries (damage to the soft tissue and skin caused by pressure or shear forces) to the left and right heels and had the potential for complications that included pain, infection, tissue necrosis, delayed wound healing, and reduced mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had the right to participate in self-care as indicated in the resident's care plan titled ADL (activities of daily living) self - care promoting independence and autonomy for one of three sampled residents (Resident 1). This deficient practice violated the residents ' rights to participate in his or her own care and had the potential to create emotional distress leading to loss of autonomy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 2), who was assessed by the facility as a high risk for developing pressure ulcer (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence due to unrelieved prolong pressure in combination with shear) and was admitted without pressure ulcers received the necessary care and services to prevent PU as indicated in the facility's policy and procedure. Resident 2 was observed with Stage 2 PU (a partial-thickness skin loss that appears as an open sore or blister) in the sacrococcyx (tailbone) that was not previously assessed and identified by the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received treatment and services in accordance with professional standards of practice and the facility's policy and procedures on Fall Management Program, revised 3/13/2021 and Completion & Correction, revised 1/1/2012 for one of two sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 had appropriate footwear as indicated in the resident's care plan and on oxygen while ambulating as indicated in the physician's order, during the time of fall incident on 1/13/2024. 2. Perform neurological check monitoring immediately after the fall incident on 1/13/2024 as indicated in the facility's fall management protocol, to perform neurological checks at the ordered frequency every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for 4 hours. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plans for two of five sampled residents (Resident 1 and Resident 2) ensuring care plan was revised following Covid 19 infection. This deficient practice had the potential to affect the provision of care for these affected residents.

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

Inspectors wroteBased on interview and record review, the facility failed to promote the resident's rights of four (4) of eight (8) alert and oriented resident (23, 26, 31, and 58) who attended the Resident Council meeting (meeting held in the facility attended by the residents) reported they were not informed of the State Long Term Ombudsman program (a program consist of resident advocacy group that promotes resident's rights) and/or provided with the telephone numbers and/or email on how to contact the Ombudsman's office. This deficient practice had violated the resident's rights, and a potential not to receive residents' assistance from resident advocacy group should unresolved issues arise in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Dietary Aide (DA) 1 washed her hands properly before touching the clean dishes after sorting the dirty dishes in a dish rack and pushing the dish rack into the dish washer. This deficient practice had the potential to cause food-borne illnesses (diseases are caused by eating food contaminated with bacteria, viruses, parasites or chemical substances) to the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure three of three sampled Residents (Residents 89, 77, and 193) were informed and verbalized understanding of the concept of the proposed arbitration (solving disputes with a neutral third party instead of the court) and the Binding Arbitration Agreement (BAA, a binding agreement by the parties to submit to arbitration all or certain disputes between them in respect of a defined legal relationship, whether contractual or not) before having Residents 89,77, and 193 signed and entered into a binding arbitration agreement. The deficient practice resulted in Residents 89, 77, and 193 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs for one of one sampled resident (Resident 288) in accordance with the facility's policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 288 not able to call the facility staff to ask for help or assistance specially during emergency.

Inspectors wroteBased on interview and record review, the facility failed to maintain a current copy of the resident's Advanced Healthcare Directive (AHCD, a legal document that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) in the resident's medical record for one (1) of one (1) sampled residents (Resident 69). This deficient practice had the potential for Resident 69 to not have her wishes met regarding life-sustaining treatment (any treatment that serves to prolong life without reversing the underlying medical condition).

Inspectors wrote2. During a review of Resident 66's Record of admission indicated the resident originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), pulmonary fibrosis (lung tissue becomes damaged and scarred), and disorder of kidney and ureter (organs that collects and drains out urine from the body). During a review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/3/2024 indicated cognitive skills (ability to make daily decisions) was intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan to address the resident's medical and physical needs for one of one sampled resident (Resident 28), had a physician order to receive Amoxicillin-Pot Clavulanate (a medication used to treat bacterial infections) tablet and Tylenol (medication used for aches and pains) tablet for tooth infection and tooth pain on 5/6/2024. This deficient practice had the potential to affect Resident 28's quality of care and quality of life by not receiving the appropiate interventions for the dental care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a post fall intervention for one of two sampled residents (Resident 13) who was at high risk for fall, by not having a bed alarm (alarms to alert staff to respond quickly and intervene to assist the patient, thus preventing a fall) and bilateral floor mats (placed adjacent to the bed may prevent injury for those prone to rolling out of bed) placed as indicated in the resident's plan of care. This deficient practice had the potential for Resident 13 to have a recurrent fall that could cause serious injury and compromise the resident's well being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident was free from significant medication error by not omitting Carvedilol (medication used to treat high blood pressure) during medication pass observation for one of five (Resident 67) sampled residents. This deficient practice had the potential to cause complications of hypertension hypertension (high blood pressure) and lead to heart attack ( lack of blood flow to the heart), heart failure(failure of the heart to meet the body's demand) and stroke-poor blood flow to the brain results in cell death).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medications and/or treatment supplies for one of one sampled residents (Resident 26) who was observed with opened tube of Fluocinonide (medication used to treat many skin disorders), opened tube of hydrocortisone (medication used to help relieve redness, itching, swelling, or other discomfort caused by skin condition), and unopened tube of Ketoconazole (used to treat fungal skin infection) in the wash basin on Resident 26's bedside table. These deficient practices had the potential for other residents to use medications that could cause cross contamination of infection and/ or consume by other residents with cognitive impairment that could be harmful to their wellbeing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure one of two sampled residents (Resident 55) with history of weight loss was assessed and served food that the resident preferred. This failure had a potential to result in Residnet 55's continued or recurrent weight loss due to that could result in a decline in the resident's well being due to not receiving food items of her choices.

Inspectors wroteBased on interview and record review, the facility staff failed to ensure one of two sampled residents (Resident 288) who was receiving hospice care services (hospice care is a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spriritual needs at the end of life) collaborated with hospice agency on the resident's plan of care by ensuring the plan of care was in the resident's medical record binder. This deficient practice had he potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 288.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility staffs implemented the facility's policy and procedure titled Resident Isolation - Categories of Transmission-Based Precautions (precautions to prevent spread of infection) to wear isolation gown when taking care of one of two sampled residents (Resident 55). Resident 55 was ordered by the physician to be placed on contact isolation (precautions steps that healthcare facility visitors and staff need to follow before going into a patient's room, used for patients with diseases caused by bacteria and virus that are spread through direct and indirect contact). This failure had a potential to result in the spread of infection to the facility's staffs and residents and could cause a decline in other residents' health.

Inspectors wroteBased on observation and interview the facility failed to ensure one of one sampled resident (Resident 34) was provided with safe and comfortable environment by failing to ensure the resident's restroom had a functional toilet's handle. This failure resulted in Resident 34's feeling uncomfortable when manually flushing the toilet and lifting the toilet water tank lid by herself to manually flush the toilet, that could potentially cause accidents and injury to resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the room space were at a minimum of 80 square feet (Sq. Ft.- a unit of measurement) for 2 out of 42 residents rooms (Rooms 25 & 26). The two resident rooms consisted of two beds each. room [ROOM NUMBER] was not occupied by a resident and room [ROOM NUMBER] was occupied by Resident 82. This deficient practice had the potential to negatively impact the quality-of-care and the ability of the nursing care to safely provide care and privacy to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement comprehensive person-centered care plan for one of three sampled residents (Resident 2) who required one-to-one staff supervision (sitter) and monitoring of the placement of wander guard, to reflect the current interventions and assessment to meet the immediate needs of the resident. This deficient practice in establishing, documenting, and implementing the care and services to be provided to the resident has the potential to negatively affect the physical well-being of Resident 2 and could potentially place the resident at risk for harm or injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 implement the facility ' s policy and procedures titled Receiving Controlled Substances (controlled medications), by failing to: 1. Reconcile controlled drug records with valid orders and administration record to detect irregular controlled medications activities and identify inventory discrepancy that occurred after a resident had been discharged from the facility. The facility accepted a pharmacy delivery of Norco for Resident 1 after Resident 1 had been discharged from the facility. The facility did not have a record of the physician order that matched the aforementioned delivery. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent treatments and services were implemented to promote the healing and prevention of pressure ulcers (wound caused when an area of skin is placed under pressure) for one of four sampled residents (Resident 1). 1. The facility did not update Resident 1's pressure ulcer treatment order as recommended by Medical Doctor (MD) 2. The facility did not create a care plan for Resident 1 ' s Stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer. 3. The facility did not completely document Residents 1's pressure ulcer treatments provided ,as indicated on the Treatment Administration Record (TAR) from January 2023 to March 2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement fall interventions for 1 of 3 sampled residents (Resident 1) who was identified as high risk for falls. 1. The facility did not place Resident 1 (R 1) close to the nurse ' s station after R1 ' s sustained a fall on 2/20/2024 with a nasal fracture. 2. The facility did not follow fall care plan goal for no fall related injury. 3. The facility did not follow fall care intervention for fall related injury. These deficient practices resulted in R1 falling on 1/25/2024/, 2/16/2024 and sustaining a nasal fracture after falling on 2/20/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from physical restraints, when Licensed Vocational Nurse (LVN) 1 placed both bed side rails up and dressers on both sides of the bed to prevent one of three sampled residents (Resident 1) from getting out of bed, without a physician ' s order and on-going assessments, in accordance with the facility policy and procedure on Bed Rails and Restraints. This deficient practice had the potential to place Resident 1 for accidents due to the use of bed side rails and dressers on both sides of the bed, without physician orders and ongoing assessment.

Inspectors wroteBased on interviews and record reviews, the facility staff failed to implement the facility's policy and procedure, titled Abuse - Reporting and Investigations, by identifying, protecting, reporting, and initiating an investigation immediately from a suspected abuse allegation brought up by a resident's family member (FAM 1) to facility staff on 11/23/2023, 11/24/2023, and 11/25/2023, for one of four sampled residents (Resident 1). The facility failed to: 1. Identify an allegation of abuse against CNA 1 by Resident 1, when FAM 1 reported on 11/23/2023 to a night shift (11 p.m. to 7 a.m.) facility staff (unable to recall clear staff name), on 11/24/2023 to LVN 1 during the dayshift (7 a.m. to 3 p.m.), and again on 11/25/2023 to LVN 1 during the dayshift (7 a.m. to 3 p.m.), and on 11/25/2023 to CNA 2 during the evening shift (3 p.m. to 11 p.m. shift). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident abuse for one of one resident (Resident 1) to the Department, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement, within two hours. This failure had the potential for Resident 1 to be at risk of further abuse.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide treatments and services for two of two sampled residents (Residents 1 and 2) by failing to: 1. Ensure Resident 1's food allergy and allergic reaction to fish were transcribed and verified in the resident's Dietary Profile and Meal Ticket, in accordance with the facility's policy and procedure on Food Allergies and Reference Sheets, and Diet Record Maintenance to alert facility staff of the resident's food allergies. 2. Ensure Resident 1's care plan (a nursing care plan provides direction on the type of nursing care the individual may need) on food allergy was developed to include the type of allergic reaction manifested by the resident and implemented the care plan on food allergy (fish allergy) to ensure Resident 1 was free from allergic reaction. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meals did not contain food allergens (a substance that causes an allergic reaction) for two (2) of 2 sampled residents (Residents 1 and 2) with known food allergies, in accordance with the facility's policy and procedures titled Food Allergies and Reference Sheets, by: 1. Serving fish and fish containing products to Resident 1 who was allergic to fish. The facility was aware Resident 1 had fish allergy but Resident 1 was served fish on 11/24/2023 (tuna salad sandwich) and 12/1/2023 (lemon ginger fish). 2. Serving wheat (a cereal that yields a fine white flour used chiefly in breads, baked goods, and pastas) containing foods to Resident 2 who was allergic to wheat. [...]

Inspectors wroteBased on interview and record review the facility failed to revise and implement the resident's care plan with accurate and updated information regarding allergies and allergic reactions for one of three sampled residents (Resident 4) with documented food/drug allergies. This deficient practice had the potential to delay care and service provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practice, when two (2) of 2 staff were observed wearing a watch and bracelets in the kitchen. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one place to another) that could lead to foodborne illness (an illness caused by contaminated food and beverages) to 93 of 96 medically compromised residents who received food from the kitchen.