Arbor Post Acute

Inspectors wroteBased on record review and interview, the facility failed to ensure the individual designated as the Dietary Manager met the qualifications required to direct food and nutrition services, including certification as a Dietary Manager or other qualifying credentials for one of one dietary managers. This failure had the potential to result in all residents receiving food and nutrition services that were not provided in accordance with professional standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain refuse (garbage) and debris (bits of trash) in a manner that minimized pests harborage (safe shelter, protection and suitable conditions to live, breed and thrive), by allowing trash receptacles to overflow, remain uncovered, and become soiled with food debris, and by permitting discarded remodeling materials and equipment to accumulate on the premises. This failure increased the risk of pest harborage and contamination, affecting all residents, staff, and visitors within the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure menus and portions sizes were followed for 21 of 118 residents when pureed foods were not prepared according to the menu instructions and the wrong portion size was served for soft and bite sized vegetables. This failure placed residents at risk of receiving meals that did not meet the planned nutritional standards, potentially affecting nutritional intake and dietary consistency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed in the kitchen when:1. Proper hand hygiene was not performed.2. Cross contamination was observed during food prep.3. Plastic plate covers were worn with rough, uncleanable surfaces. These failures posed a risk for foodborne illness in 118 residents who received food prepared in the kitchen.

Inspectors wroteBased on interview, facility policy, and record review, the facility failed to ensure the procedures for reporting alleged abuse were implemented when Licensed Nurse (LN) O did not report an allegation of abuse for one of 29 Residents (Resident 63), immediately or within 2 hours to the California Department of Public Health (CDPH), Ombudsman (resident advocacy group), local law enforcement and the facility Administrator. This resulted in a delay in protecting Resident 29 from further abuse and had the potential to delay investigations and protection of all residents from ongoing abuse and mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a routinely prescribed medication was available and administered as ordered for one of seven sampled residents (Resident 102). This failure placed the resident at risk for worsening gastrointestinal symptoms and pain.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two of 19 kitchen employees demonstrated the competency and skills necessary to safely perform daily kitchen duties when:1. Proper hand hygiene was not performed.2. Cross contamination was observed during food prep.3. Resident menus and recipes were not followed.4. Temperatures were not properly taken for tray line. This failure had the potential to result in unsafe food handling practices, increasing the risk of food contamination and foodborne illness for 118 residents who received food prepared in the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accommodate the needs for one out of two sampled residents (Resident 1) when bed canes (a device that was like a grab bar, attached to the bed, and designed to help residents move, reposition, or transfer out of bed) were recommended and not provided in a timely manner. This failure caused Resident 1 to depend upon staff for bed mobility (movement) and had the potential to cause a decline in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observations, interviews, and record reviews the facility did not ensure Physician ordered services were provided to one out of two sampled residents (Resident 1) when specialized rehabilitative services (expert led therapy program to help individuals improve on daily function and return to normal life) were not provided. This had the potential for Resident 1 not to attain or maintain their highest practicable level of physical, mental, functional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents sampled for falls with injury was provided with the necessary care to prevent an avoidable fall with injury (Resident 1) when the facility failed to;1. Take Resident 1 to the bathroom on 3/9/25, after her family member (FM) told staff that she needed to go. Subsequently, Resident 1 got up on her own to use the bathroom and fell. This failure to toilet Resident 1 resulted in Resident 1 falling and sustaining a broken right ankle, foot and toes which caused her severe pain, a transfer to the hospital, and delayed her discharge back home by 6 weeks. (Refer to F600 and F697)2. Ensure Resident 1 was assigned a Certified Nursing Assistant (CNA) to take care of her on the PM shift (2:30 pm to 11 pm), on 3/9/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of three residents, sampled for abuse, (Resident 1) the right to be free from neglect due to the deprivation of goods and services by Licensed Nurse (LN) A when Resident 1 had pain in her broken right ankle and LN A indicated she was too busy to dispense Resident 1 pain medication. This resulted in Resident 1 experiencing unnecessary unrelieved pain and discomfort to right ankle and had the potential to negatively impact her physical and emotional well-being. FindingsA review of the facility's policy titled Identifying Types of Abuse revised 9/22, indicated abuse of any kind against residents is strictly prohibited. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure pain management was provided for one of three residents sampled for pain management (Resident 1) when Resident 1 had pain in her right ankle rated at a 5 (on a pain scale from 0-10 with 0 being no pain and 10 being severe pain) and was not medicated with pain medication as indicated in her physician's orders consistent with her pain level. This resulted in Resident 1 experiencing unrelieved moderate pain and tenderness to right ankle and had the potential to negatively impact her physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety and security of seven of seven residents (Residents 1, 2, 3, 4, 5, 6 and 7) sampled as those who had been identified as high risk for wandering and/or elopement (when a resident unsafely leaves the facility undetected) when: 1. The Touchpad Exit Controller (TEC, a system located on exit doors that alarms when resident wearing a Wanderguard (a wrist or ankle bracelet that alarms), passes through any of those exits), alarm system did not alarm and Resident 1 eloped from the facility without staffs knowledge, and Resident 1 was found across the street from the facility by a person who was driving by, with his wheelchair stuck in a sidewalk crack. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility violated a request for refusal of treatment for one of two residents sampled for resident rights (Resident 1) when, Resident 1 requested no artificial means of nutrition, including feeding tubes (Gastrointestinal Tube(G-tube)), a flexible tube that is placed through the abdominal wall and into the stomach for feeding liquid nutrition), because he wanted to eat and drink regular food and liquids, and the facility continued to feed Resident 1 by G-tube for 24 days after he had signed a Physician Order for Life Sustaining Treatment (POLST, a document of resident wishes). This failure caused Resident 1 distress, frustration and pain and negatively impacted his quality of life.

Inspectors wroteBased on interview, record and facility policy review, the facility failed to recognize and report a change in condition to the physician, conduct weekly skin wound evaluations as their policy directed, and carry out physician's orders for antibiotic (medication for treating infections), for one of three residents sampled for wound care (Resident 1) when: 1. Resident 1 had a surgical wound to her upper left leg that had worsened on 3/29/24, and her physician was not notified. 2. Resident 1's weekly skin evaluations of her wounds, were not performed weekly. 3. Resident 1 had orders from her vascular surgeon (a doctor who specializes in treatment of blocked arteries and veins), to begin taking an antibiotic on 4/10/24, that were never carried out. These failures had the potential to delay the healing process of Resident 1's wounds and contribute to Resident 1's hospital readmission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's plan of care met their needs and provided supervision required to keep them free from accidents and hazards for two of five sampled residents (Resident 250 and 303) when: 1. Resident 250 was known to the facility to have restless/aggressive behaviors, active infection and had been evaluated to be at a high risk for falls. The facility failed to re-evaluate past interventions, identify the root cause of Resident 250's falls and develop resident specific individualized interventions to prevent accidents. This resulted in repeated falls for Resident 250 and subsequently, a bilateral head injury that required a 12-day hospitalization. 2. Resident 303 a) Was not identified as a smoker on admission but was seen smoking on the sidewalk. b) Smoked off campus without facility knowledge. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their pain management policy and identify causes of pain, implement pain management strategies, and monitor or modify approaches to ensure pain was adequately controlled for one out of 4 sampled residents (Resident 76) when: Resident 76 screamed out in pain when staff changed her brief (adult diaper), because staff forced her contractured legs (a permanent and irreversible deformity of a joint caused by the muscles and tendons shortening and stiffens the joint and causes an inability to move. Forcing a contractured body part such as arms, legs or neck, to move farther than the position it is fixed in, causes severe pain, muscle damage and broken bones). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the environment was maintained in a safe, clean, comfortable and homelike manner when: 1. Resident 5's mattress was uncomfortable. 2. Resident shower rooms had broken tiles, the showers and dining room was cold, and room [ROOM NUMBER]'s heater/AC unit had metal tape around it with exposed wall and insulation. This had the potential for residents to feel uncomfortable in their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe and effective use of medications when: 1. Resident 302 found a pain pill at her bedside when she woke up. This failure caused anxiety for Resident 302 and the potential for a decline in her psychosocial and physical well-being. 2. The policy for medication storage was not implemented for two out five sampled medication carts. This failure resulted in putting residents at risk for harm from receiving expired and potentially contaminated or ineffective medications. 3. Narcotic disposal logs were inaccurately maintained, as there were missing names and signatures of licensed nurses in four out of 125 instances of narcotic disposal between 11/13/24 to 1/6/25. This failure had the potential to allow for drug diversion (when medication is taken for use by someone other than whom it is prescribed for).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an infection prevention program was maintained to prevent the spread of infection when: 1. The wheelchairs (W/Cs) for Residents 1, 2, 13, 46, and Resident 133 were visibly unclean and soiled. 2. The oxygen tubing for Resident 72 was not stored appropriately while not in use. 3. Personal hygiene products were not stored properly for Resident 62 and Resident 133. 4. An unkept and worn elevated bedside commode was used for Resident 87. 5. Certified Nursing Assistant (CNA) B did not perform hand hygeine after touching self during a dining observation. These failures had the potential for the spread of infection throughout the facility to each client which could lead to negative clinical outcomes including transmission of food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect by direct care staff during activities of daily living for two out of five sampled residents when: 1. Resident 44's room door and privacy curtains were open, exposing her back and chest. 2. Resident 68 did not receive assistance with toileting and a request for a food preference at breakfast. This resulted in Resident 44's privacy and dignity to be violated and Resident 68 felt cold and uncomfortable.

Inspectors wroteBased on observation, interview, and record review, the facility direct care staff failed to place the call light within reach for two of four sampled residents, (Resident 39 and Resident 87). This failure had the potential for resident specific needs and requests to not be met in a timely manner, and the potential for negative clinical outcomes to include the potential for a fall.

Inspectors wroteBased on interview and record review, the facility failed to protect the rights of one of four sampled residents' (Resident 22) to be free from sexual abuse when Resident 120 was observed by staff to hold Resident 22's hand in his unzipped pants. This failure placed all residents at risk for potential sexual abuse and/or mental anguish from Resident 120.

Inspectors wroteBased on interview and record review, the facility failed to report sexual abuse to the State Agency (SA) and family in the mandated timeframes for one of four sampled residents (Resident 22). This failure delayed an investigation of the incident and created the potential for ongoing resident-to-resident sexual abuse for residents within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate resident assessments for two of 29 residents (Resident 68 and 303) when: 1. Resident 68 was assessed as continent (able to control bladder which holds urine) when she was occasionally incontinent (not able to control her bladder). 2. Resident 303 was assessed as a non-smoker but was a smoker and was observed smoking. This failure had the potential for inaccurate resident care planning and adverse health outcomes for Resident 68 and Resident 303. Findings 1. A review of the facility's policy, Facility Assessment dated 8/6/24, indicated the purpose of the assessment is to determine what resources are necessary to care for residents competently both during day to day competencies and emergencies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services that met professional standards of quality for two of nine residents when: 1. Resident 69's physical needs were not accommodated when Durable Medical Equipment (DME) was not provided by the Therapy Department. 2. Resident 68 did not receive needed medical referrals. This failure had the potential to result in emotional stress, anger, depression, feelings of neglect, and the potential for negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary assistance for Activities of Daily Living (ADLs, activities related to personal care) for dependent residents for two of six sampled residents, (Resident 68 and Resident 69) when: 1. Resident 69 did not get out of bed (OOB) due to not having an appropriate wheelchair (W/C) to meet his specific needs; and 2. Resident 69 did not receive scheduled showers, or as needed showers for January 2025; and 3. Resident 68 did not receive assistance for toileting using a bed pan (device to collect urine while lying or sitting in bed) upon request. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the residents from achieving their highest practicable level of physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 1 of 29 sampled residents (Resident 44) with quality of care that met their needs when Resident 44 did not receive adequate foot care (washing, applying lotion, and assessing the skin). This failure resulted in discomfort and dry, cracked, and peeling feet for Resident 44. A review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 10/2024, indicated: 1. Residents will be provided care, treatment, and services as appropriate to enable them to carry out ADLs, for example, bathing, dressing, oral hygiene, walking, transferring in bed, toileting, and eating. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 123), was turned and repositioned as ordered to prevent skin break down, promote circulation, and provide pressure relief. This failure resulted in areas of redness to Resident 123's skin and wrinkles to her skin from the bed linens and the potential to contribute to Resident 123 developing a pressure ulcer (open area of the skin, or bedsore caused by prolonged pressure) which could lead to complications including pain, discomfort, and infection.

Inspectors wroteBased on interview and record review, the facility failed to do a performance evaluation every year for one out of two sampled Certified Nursing Assistant's (CNA) M employee file reviews. This had the potential for CNAs not to receive ongoing education/inservices based on the outcome of their annual review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be free of medication error rates of five percent (%) or greater when five medication errors were observed out of 26 opportunities. The medication error rate was 19.2 %. This failure resulted in multiple medication errors and had the potential for the residents not to receive medication as their physician's ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications in two out of two sampled medication storage rooms. Disorganized storage of medications in a nursing home can lead to medication errors, delays in treatment, and potential adverse health effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Resident 98's perishable food was stored in the refrigerator rather than at his bedside, and his expired food was discarded. 2. Descaling (the process of removing a hard, white layer of limescale - a hard chalky buildup of calcium left over from water - from an object) and sanitizing (a process to reduce the number of microorganisms to safe levels) of the ice machine was performed per the manufacturer's instructions. These failures had the potential: 1. To place Resident 98, a medically vulnerable resident, at risk for foodborne illness related to the growth of microorganisms (bacteria or fungus that cause nausea, vomiting, and diarrhea). 2. For the facility ice machine to become contaminated with microorganisms, putting all residents consuming ice from the ice machine at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policies were established and implemented regarding smoking safety for one of two sampled residents (Resident 303) when: 1. Resident 303 smoked on the sidewalk in front of the facility and the facility had not identifed him as a smoker because the facility had no policy or procedure to identify residents who smoked while off the facility property. 2. Resident 303 kept his cigarettes and lighters in his room unsecured because the facility had no policy or procedure to identify and manage resident smoking materials (cigarettes and lighters) for residents that smoked while off the facility property. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff provided competent nursing care for one of five sampled residents (Resident 1), who had a change in their condition and the physician was not notified. This failure resulted in Resident 1 being transferred out of the facility by ambulance and had the potential to negatively impact the safety, physical, and emotional well-being of any resident who experienced a change in their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents was communicated with in a language that she could understand (Resident 1), when Resident 1 only spoke Spanish and the facility failed to provide an interpreter. This failure resulted in Resident 1 not understanding why she was moved to a new room and negatively impacted her emotional and psychosocial well-being, and had the potential to affect all residents who ' s primary language was not English.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents was notified of a room/roommate change with a written notice that included the reason before the facility had the resident ' s room changed (Resident 1). This failure resulted in negatively impacting Resident 1 ' s emotional and psychosocial well-being due to being upset and without proper notification and/or understanding of the room change.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three residents sampled residents (Resident 1), had reasonable access to the use of a telephone in the facility without their calls being overheard. This failure resulted in the resident not having enough privacy to speak to the Ombudsman (an individual that assists residents with their concerns), on her own and voicing her concerns properly without facility staff being present.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, comfortable homelike environment for eight residents (Residents 1, 2, 3, 4, 5, 6, 8 and 9) among a facility census of 134, when their bathrooms appeared dirty and in disrepair. This failure had the potential to threaten the residents ' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to directly involve one of 22 sampled residents (Resident 1), and their Responsible Party (RP, a person designated to make decisions on behalf of a resident) in a treatment decision, when the RP was not notified of, and a consent for an Ear, Nose and Throat (ENT) consult was not obtained prior to treatment. This failure resulted in Resident 1 receiving treatment by an ENT that the RP was not informed of and did not approve of.

Inspectors wroteBased on interview, and record review the facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standard for 1 of 1 sampled residents (Resident 1) when: 1. Resident 1 had a change of condition and medication was ordered by the physician but there were no nurses notes describing the condition of Resident 1. 2. An Ear Nose and Throat Practitioner (ENT, an outside provider) did rounds in the facility and saw Resident 1 and no documentation of the visit were in the residents' medical record. These failures had the potential to prevent accurate information for Resident 1 regarding medical care and condition to be available to the residents, their representatives and other care providers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident shower rooms on Station 1 and Station 2 were safe, sanitary, and comfortable when floor tiles had black and brown areas in the grout (a mixture of water, cement, and sand used to fill voids and seal joints such as those between tiles), and the wall tiles in the shower corners were cracked and covered with a black substance. This failure placed residents at risk for being uncomfortable and exposed to possible infectious conditions while taking a shower.

Inspectors wroteBased on observation, interview and records review, the facility failed to provide a safe environment which was free from abuse for 1 of 5 samples residents (Resident 8, 10, 16, 27, and 38), when Certified Nursing Assistant 2 (CNA 2) verbally abused Resident 10 on 3/2/24. This failure caused Resident 10 to have feelings of fear and emotional distress, and affected their psychological well-being. This failure also had to potential for other Residents to be abused, when CNA 2 was allowed to continue working.

Inspectors wroteBased on interview and record review, the facility failed to meet this requirement when its Dietary Supervisor (DS), the person responsible for the day to day management and supervision of the department, did not meet the federally required training qualifications for that position. This had the potential for inadequate purchasing of food and supplies, incorrect food preparation, service and storage, according to professional standards for sanitation and safety to avoid food borne illnesses.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure dietary staff had the necessary competencies and skills when: 1. Staff did not prepare pureed food items in accordance with facility guidelines, recipes, and/or current standards of practice, and 2. One of two dishwashing staff was unfamiliar with the manufacturer's recommended test strips for ensuring dishwashing water was within a safe chlorine range, and had no record of being trained in using testing strips. This resulted in resident dissatisfaction with the flavor and consistency of purees and had the potential for foodborne illness. Findings 1. In a concurrent observation and interview on 1/23/24 at 9:30 AM, [NAME] A (CA) was observed adding what he stated was vegetable broth to what he stated was pureed zucchini. [...]

Inspectors wroteBased on interview, observation and record review, this requirement was not met when the facility failed to store and prepare food in a sanitary environment as evidenced by: 1. Kitchen fixtures/equipment and appliances that were not clean to sight or touch. 2. Bare artificial nails were worn by a kitchen staff member during food production. This had the potential to cause foodborne illness and rodent or insect infestation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained when: 1. Nurse staffing not sufficient to meet resident needs. 2. Building maintenance projects not identified or timely repaired. 3. Dietary staff not sufficient nor qualified. 4. Oxygen system to supply 129 of 143 residents in the facility who required respiratory support. This failure had the potential to affect all residents quality of life and care.

Inspectors wroteBased on interview and record review, the facility failed ensure the Director of Nursing (DON), was present during the Quality Assurance and Performance Improvement committee meeting (a meeting where managers discuss problems and improvement plans for the facility), for the last quarter of 2023. This had the potential for problems and concerns regarding resident care needs and the nursing department to go unheard.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure essential equipment was maintained and in an operating safely when: 1. A floor drain in the kitchen was backed up with dirty, stagnant water; 2. Various pieces of equipment in the kitchen were dirty and in poor repair; 3. Ice buildup was observed on a pipe above the fan in the walk-in freezer. 4. Two out of four water boilers were not functioning for a facility with 143 current residents. This had the potential to cause foodborne illness and resulted in residents to refuse showers due to uncomfortable cold water temperatures.

Inspectors wroteBased on interview and record review the facility failed to ensure resident complaints were acted upon timely and implemented plans of action to correct the identified issues. This failure resulted in ongoing unresolved resident complaints.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, homelike environment when: 1. Linoleum flooring was detached from the lower walls in bathrooms of rooms [ROOM NUMBER]. 2. Resident 118 had no overhead light to read in bed. 3. Shower Rooms on Station 1, 2 and 3 tiles were broken. This failure had the potential to negatively impact the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement culturally competent care plans for two of four non-English speaking residents (Residents 33 and 64). This failure put all non-English speaking residents at risk for physical, mental, and emotional distress due to their lack of ability to communicate with staff and others.

Inspectors wroteBased on observation, interview, and record review failed to ensure residents received the necessary care and services when: 1. A functional and effective communication system for four out of four sampled residents whose primary language was not English. (Resident 33, Resident 43, Resident 64, and Resident 286). This failure had the potential to impact the residents' right, care and lead to bias, misinformation, confusion, and physical harm. 2. Provide routine bathing (shower, bed bath) in accordance with standards for resident hygiene for 6 of 8 sample residents (Residents 21, 49, 130, 46, 800, 81). This failure had the potential to result in depression, poor self-esteem, skin breakdown, infection, and denial of resident rights, all of which could lead to negative clinical outcomes for Residents 21, 49, 130, 46, 800, 81.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents with dementia were provided meaningful activities to meet their needs for 3 of 4 sampled residents (Residents 64, 76 and 101). This failure had the potential for all residents to be at risk for decline in cognitive function and psychosocial well-being.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide sufficient nursing staff to deliver the care and services to meet the needs of the residents when: 1. Call lights were not answered in a timely manner for five out of 28 sampled residents (Residents 81, 118, 92, and 28) and a confidential resident interview. 2. Residents were not assisted with meals for four out of five sampled residents (Resident 75, 96, 130, and 9) 3. Showers were not given as scheduled for six out of eight sampled residents (Resident 49, Resident 130, Resident 76, Resident 91, Resident 800, and Resident 81). This resulted in activities of daily living needs not to be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications were stored safely when multiple pharmaceutical products were found to be expired. 2. Ensure two intravenous (medication given in the veins), infusion medications were properly disposed after the residents were discharged . 3. Ensure the medication was labeled with currently accepted labeling requirements. 4. Ensure there is no discrepancy between the number of the oral medication stored in the emergency drug kit (drug supply for emergencies), and the number of the oral medication indicated on the label of the emergency drug kit. These failures had the potential for residents to receive expired wound care products, wrong and ineffective (expired) medications, and to not receive needed medications in an emergency.

Inspectors wroteBased on interview, observation and record review, the facility failed to meet this requirement when: 1. Dietary staff prepared foods hours before of mealtimes and kept food in a steamer (table with hot water bins to keep food hot), for several hours. 2. Pureed foods were alternately thickened and thinned without following a recipe. This resulted in food complaints and had the potential for food to have lost nutritive value, texture, and palatability (general edible appeal).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain their infection prevention and control program when: 1. A Certified Nursing Assistant (CNA) assisted Residents 45 and 77 with eating lunch at the same time without sanitizing their hands in between handling the residents' utensils; 2. Linoleum flooring was separated from the walls in bathrooms of rooms 119, 121 and 123. This failure had the potential to spread germs to a vulnerable resident population which could have caused infections with negative clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed ensure a request for roommate change was accommodated for two of four residents (Resident 999 and 32). This failure resulted in loss of sleep and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and monitor one of five residents (Resident 72) for risk of elopement (leaving the building without notifying anyone) when a wander monitoring device (a device placed on a resident that caused an alarm to sound when a resident approached an exit door) was applied to Resident 72 with no physician's order, no Care Plan, and no follow-up. This failure had the potential to diminish Resident 72's quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure physician orders for oxygen were implemented for one of three residents (Resident 9) when her oxygen tank was found empty on two consecutive days in the morning. This failure had the potential for all oxygen dependent residents to be at risk for respiratory complications.

Inspectors wroteBased on interview and record review the facility failed to ensure that a pain assessment was done and that pain medications were aquired and available to be given for one of five sampled residents (Resident 92), when Resident 92 expressed that her pain level was 10.5 out of 10 (on a scale from 1 to 10, with 10 being the worst pain imaginable), upon admission to the facility. This failure to aquire pain medications for Resident 92 resulted in severe and uncontrolled pain for this resident and required that she be transferred back to the hospital within 7 hours after she was admitted to the facility.

Inspectors wroteBased on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours a day 7 days a week. This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were accurately documented for one of six residents (Resident 72) when a physician documented two antipsychotic (used to treat psychosis, or a loss of touch with reality) medications that the resident was not receiving. This failure had the potential to negatively impact Resident 72's care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light system was functioning and accessible for four out of four residents (Residents 69, 96, 118, 127). This failure resulted in a delayed responses to resident care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed ensure one of six residents (Resident 5) was supervised to keep him free from accidents and hazards when care plan interventions were not developed and implemented to prevent wandering/elopements, prevent falls, and injuries related to resident to resident altercations. This resulted in an elopement, wandering, falls, and resident to resident altercations.

Inspectors wroteBased on record review and interview the facility failed to recognize pain, assess pain, identify the cause of pain, and monitor and modify approaches to pain management for Resident 5. This failure resulted in uncontrolled pain and behaviors and altercations with other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure social services were provided for four of six residents (Residents 1, 2, 3, and 5) when: 1. Resident 5 had behavior issues and resident-to-resident altercations with no psychiatric referrals, no social worker notes nor care conferences in the record. 2. Resident 1 had no social worker follow-up after a resident-to-resident altercation on 09/01/2023. Resident 2's records contained no social services follow-up after the resident-to-resident altercation, and no follow up with Resident 2 after room change. 3. Resident 3 had no social services progress notes following the resident-to-resident altercation occurring 08/28/2023. This resulted in ongoing psychosocial distress and continued resident-to-resident altercations.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six residents (Residents 1 and 7) were free from abuse when: 1. On 9/5/2023 at 10:11 am, it was reported Resident 2 slapped Resident 1 in his left eye. 2. On 10/04/2023 at 1:54 pm, Resident 5 hit Resident 7 in the face. These failures resulted in resident injuries and frustration.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse/neglect for two of six residents (Residents 1 and 2). This failure had the potential for all residents to be at risk for resident-to-resident altercations and abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the investigative results for two of three facility reported incidents involving resident to resident altercations were sent to the state survey agency with 5 working days of the incidents. These failures resulted in ongoing resident-to-resident altercations, which could lead to negative clinical outcomes.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Physician's order and arrange for recommended Home Health services (nursing and/or therapy provided in the home after discharge), when they discharged one of three sampled residents home (Resident 1). This failure had the potential for Resident 1 not to attain or maintain his highest practicable physical, mental, and psychosocial well-being and had the potential for a hospital readmission.

Inspectors wroteBased on interview and record review, the facility failed to maintain an environment safe and free from abuse for 1 of 5 sampled residents (Resident 2), when Resident 1 poked Resident 2, then followed Resident 2 to Resident 2's room and slapped Resident 2's face. This failure had the potential of causing harm, pain, and emotional distress which may result in a negative impact on the resident's health issues and overall wellbeing, both physically and psychologically.

Inspectors wroteBased on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse for one out of four sampled Residents (Resident 1), when Resident 1 was slapped on the face by Resident 2. As a result, Resident 1 had redness and swelling on her face, and she was crying.

Inspectors wroteBased on observation, interview and record review, the facility's Administrator failed to administer the facility effectively and efficiently in a manner that ensured the needs of the residents were met when: 1. The Administrator falsely presented herself as a licensed Nursing Home Administrator and was not qualified to act in the capacity. 2. The Administrator had not ensured that there was a Director of Nursing (DON), to evaluate the delivery of clinical services, admissions and monitor resident outcomes. 3. The Administrator failed to ensure there were enough Registered Nurses (RNs) to administer physician ordered medications. 5. The Administrator failed to ensure all licensed nurses in the building had a current license. [...]

Inspectors wroteBased on observation, interview, record and document reviews, the facility's Governing Body (facility owners, executives, or other individuals who are legally responsible for the management and operations of a facility), failed to ensure that the Administrator (individual who is responsible for the facility's operating budget, supplies, staff and any other services necessary for the care of the residents), they appointed had a valid Nursing Home Administrator's (NHA) license issued by the State of California's Nursing Home Administrator Program (NHAP, the State Department that ensures that resident's rights are safeguarded and that all qualifications and background checks are met before they will issue a NHA license). [...]

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI), when the committee did not develop, implement, and identify performance improvement activities related to quality of care and life when: 1. Residents right to be comfortable in their home was not honored. This resulted in a decrease in quality of life when residents reported staying in their rooms, sleeplessness and frustration about the AC not working in the facility. 2. Ensure sufficient Registered Nurse and Director of Nursing staffing required for the oversight of care provided to residents in the facility. This resulted in missed doses of an antibiotics and had the potential to delay healing and discharge from facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the temperatures were at comfortable levels for resident rooms, hallways and common areas on Station 3 and Station 4. These failures resulted in residents to be uncomfortable, stay in their rooms, sleeplessness, and frustration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient licensed nursing staff to meet the needs of the residents when: 1. A Registered Nurse (RN) was not available 8 hours a day This resulted in Resident 1 not to receive a antibiotic via a Peripherally Inserted Central Catheter (PICC, thin, soft, long tube that is inserted into a vein for medications). 2. Director of Nursing (DON) was not replaced timely for a planned leave of absence. This resulted in decreased RN coverage and oversight of daily resident admission screening to ensure residents needs were met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure equipment in the facility was maintained when the Central Air Conditioning (AC) system and Packaged Terminal Air Conditioners (PTAC, a standalone AC/heater, self-contained, meaning they do not rely on ducts to operate) on Station 3 and 4 were not working. This resulted in an uncomfortable temperature during the summer months and resident discomfort.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered as per physician orders when Resident 1 did not receive a necessary antibiotic to treat a severe infection. This resulted in 3 missed doses of an antibiotics and had the potential to delay healing and discharge from facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from physical abuse from a Certified Nursing Assistant, (CNA), when CNA E was witnessed by staff throwing a piece of bread at Resident 1. This failure resulted in physical abuse for Resident 1 and the potential for all residents to be at risk for physical abuse and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to report the results of an investigation of staff to resident abuse to the California Department of Public Health (CDPH) within five days for one of two sampled residents (Resident 1) when the five-day report was not submitted to CDPH following . This had the potential to put all residents at risk for abuse from staff at the facility.