Atherton Park Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection prevention and control program when two of five sampled staff did not receive N95 respirator (a mask that filters airborne particles very effectively) fit testing (a process used to determine N95 respirator fits properly). This failure had the potential for spread of airborne infections (an illness that spreads through tiny germs in the air that people can breathe in) to the residents, staff, and visitors. During an interview on 4/16/26 at 10:45 AM, Licensed Vocational Nurse (LVN) 1 stated the facility uses N95 respirators when there is a COVID-19 (an illness caused by a virus that spreads easily through the air) outbreak. LVN 1 opened a plastic cabinet with drawers containing N95 respirators, and stated, We have them here. These are what we use. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate services to one of three sampled residents (Resident 1) when the Registered Dietitian (RD) did not reevaluate and address Resident 1's severe weight loss (a weight loss greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months). This failure placed Resident 1 at risk for decline in nutritional status and physical health. Resident 1 was admitted on [DATE] with diagnoses that include left distal radius fracture (a break of the bone near the wrist of the left forearm) and cerebral palsy (a condition that affects a person's ability to move and maintain balance and posture). Resident 1 was transferred to acute care hospital on 7/2/25 and was discharged from the facility on 7/9/25. Review of Resident 1's weight record indicated an initial weight of 230 pounds on 5/23/25. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure windows on the 2ndfloor were: 1. Secure from opening greater than 4 inches to prevent confused residents from jumping out windows. 2. Inspected on a regular basis to ensure window securing devices were still functioning. 3. Secure window with a device that is tamper proof. Failure to secure 2nd floor windows had the potential for confused residents to sustain serious injuries if they jump out of these windows.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan (a detailed approach to care customized to an individual resident's needs) for one of 2 sampled residents (Residents 1) when the elopement (the act of leaving a facility unsupervised and without prior authorization) care plan was not applicable for Resident 1 after he eloped the facility on 4/14/25. This deficient practice was likely to fail to meet Residents 1's nursing needs and goals to attain his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment to two of two sampled residents (Resident 12, and Resident 136) when Residents 12 and Resident 136 shared the same bedroom with a resident in bed C (Resident 68) who repeatedly yelled and screamed. The facility failure to provide comfortable and homelike environment had the potential to negatively impact the psychosocial well-being of Resident 12 and Resident 136.

Inspectors wroteBased on interview, and record review, the facility failed to inform and provide written information to residents or residents' representatives to formulate advance directives (A legal document indicating resident preference on end-of-life treatment decisions) when there was no evidence of offering and educating the advance directives to 13 out of 30 sampled residents (Residents 17, 21, 29, 31, 39, 46, 67, 68, 93, 94, 136, 139, and 317). These failures were likely to result in not following the residents' desired health care decisions when they become unable to make decisions for themselves.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and specific interventions for four of 30 sampled residents (Residents 77, 143, 93, and 136) when: 1. For Resident 77, there was no evidence of comprehensive care plan for his hearing difficulty. 2. For Resident 143, there was no evidence of comprehensive care plan for the use of Eliquis (anticoagulant, commonly known as a blood thinner, drugs that prevent blood clots from forming). 3. For Resident 93, there was no evidence of comprehensive care plan for suicidal ideation. 4. For Resident 136, there was no evidence of comprehensive care plan for depressed mood. These deficient practices were likely to fail to meet the residents' nursing needs and goals to attain their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety when the chopping boards were in poor condition. The facility failure had the potential to cause food borne illness for 153 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate plan for staff monitoring and intervention for Resident 93 who had suicidal ideation when the facility did not develop a plan and coping skills and update assessments which should have led to timely updating of resident care plan for safety. The facility failure had the potential for resident harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 138) understood the arbitration agreement (a contract in which parties agree to resolve disputes), signed during admission to the facility. This deficient practice resulted in Resident 138 signing the facility's arbitration agreement without full understanding.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assess the resident for self -administration of medications for Resident 1, when four bottles of medications found in her purse. This failure could result in medication overdose or medication interaction, as these medications are not in MD order.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident is informed of her rights and her rights are protected when: Resident 1 did not have a signed admission agreement and resident received opened mails and packages. This failure resulted in resident in resident feeling disrespected.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that Resident 1 was provided pain management based on a comprehensive assessment after the incident, incident 1, when her right foot got caught while CNA wheeling resident in her wheelchair without foot rest inside the room, incident 2, while coming out of third floor elevator, right foot got caught again in the wheel of the wheelchair, incident 3, resident complained of pain, wanted to go back to bed, not able to do bike exercise due to pain. Resident 1 called 911 due to pain. This failure resulted in Resident 1 suffering from severe pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pre employment background check was completed for a Certified Nurse Assistant (CNA) 1 before allowing to work at the facility. The facility's failure had the potential for residents to experience abuse and psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for one of 34 sampled residents (Resident 1) that includes the instructions needed to provide effective and person-centered care when there was an intervention which was not applicable upon admission for Resident 1 who was at risk for fall. This failure had the potential to place Resident 1 at risk not to receive the appropriate intervention to prevent fall.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the director of dietary services is employed when there was no kitchen manager at the facility after 10/31/23. This failure had the potential for inadequate supervision of the dietary department for 153 residents who ate food from the kitchen out of a census of 153.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when: 1. There were no expiration dates on two chicken flavored base and cranberry flavored juice cocktails in a box in the refrigerator, and one box of the beef patty in the freezer. 2. There were no dates on the ranch dressing on a tray in the refrigerator and ice creams in a cup on a tray in the freezer. 3. There were two boxes of FRESH SHELL EGGS, not pasteurized eggs in the refrigerator. 4. There were expired items in the refrigerator such as one low fat cottage cheese, mayonnaise, and hot sauce. 5. Dish machine temperature logs were not filled completely for November and December 2023. 6. Pot and pan test strip/sanitation bucket logs were not filled completely for November and December 2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment type for two of 31 sampled residents (Resident 23, 73, and 63). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control and prevention practices during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak when: 1. Licensed Vocational Nurse (LVN) 3 did not remove her N95 respirator (a respiratory protective device designed to protect against particulate matter such as dust, fumes, mists, aerosols, and smoke particulates) and face shield (to protect your eyes, nose, mouth and face from flying objects and liquids) after leaving a Resident 22's room who was on transmission-based precautions (TBP - used in addition to standard precautions for patients who are known or suspected infections with pathogens that can be transported by airborne, droplet, or contact routes). 2. [...]

Inspectors wroteThe facility failed to appropriately administer medications when Resident 74 was self-administering medications without being appropriately assessed and approved for self-administration. This situation raises concerns about medication management and the need for proper protocols to ensure patient safety and compliance with medication administration guidelines.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment for residents on the third floor when a confused resident was observed screaming. Failure to maintain a comfortable sound level could potentially negatively impact residents' quality of life, sleep, and prevent residents from hearing their devices (computer, phone, radio, television) and each other during their daily activities.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment was completed within the required timeframe of not less than once every 12 months (means 366 days) for one of 31 sampled residents (Resident 63). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs, functional and health status, preferences, and goals of care that may affect the physical, mental, and psychosocial well-being of Resident 63.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) information for three of 31 sampled residents (Resident 23, Resident 73, and Resident 63) were electronically submitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within 14 days. This failure could result to ineffective monitoring of resident's decline and progress overtime, and delayed provision of resident specific information for payment and quality measure purposes.

Inspectors wroteBased on interview and record review, facility staff failed to accurately code Resident 62's fall with major injury within his Minimum Data Set (MDS, a standard resident assessment tool), dated 06/06/2023. Failure to accurately code a MDS had the potential to transmit inaccurate clinical information to the Federal/State data base and may negatively impact Resident 62's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to implement fall care plan for one of 33 sampled residents (Resident 141) when the neuro checks were not done every shift for 72 hours for Resident 141 after his fall on 11/11/23. This failure had the potential to delay the identification of needs, functional and health status for Resident 141.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment provided meet professional standards for one of 31 sampled residents (Resident 63) when order for oxygen administration was not followed per physician's order. The deficient practice had the potential to compromise the health and safety of Resident 63.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, 2 medication errors were observed out of thrity opportunities, resulting in an error rate of 6.67%.

Inspectors wroteBased on observation and record review, the facility failed to provide a safe and sanitary environment when the countertop and sides of the 3rd floor nursing station were found chipped and damaged, and four window screens were found damaged. Damaged countertop presented sharp hazard to residents and prevent staff from properly sanitizing the surfaces. Damaged window screens have the potential to let flying pests into resident's living spaces.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision/assistance to Residents 62, 71, and 81, three of thirty-one sampled residents, to minimize their fall risks. Due to this failure, all three residents had multiple falls, and each sustained a fracture due to their falls. Additionally, lack of supervision resulted in an injury of unknown origin to Resident 105. Resident 105 was found with bleeding to his face.

Inspectors wroteBased on interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of alleged abuse/neglect in a timely manner for 5 (five) of 33 sampled residents for three incidents (between Resident 49 and Resident A, between Resident B and Certified Nursing Assistant (CNA) 8, between Resident 41 and Resident 95) when: 1. the facility reported 6 hours later to CDPH and Ombudsman after Resident 49 punched his roommate Resident A. 2. the facility reported 2 days later to CDPH and Ombudsman after Resident B was found with blankets wrapped around his waist with his arm caught inside restricting his mobility. 3. the facility reported 1 day later to CDPH and Ombudsman after Resident 41 hit Resident 95. [...]

Inspectors wroteBased on interview, and record review, the facility failed to update the abuse care plan for one of 33 sampled residents (Resident B) when he was found with blankets wrapped around his waist, with his arm caught inside restricting his mobility. This failure had the potential to put the resident at risk of not receiving appropriate care.

Inspectors wroteBased on interview and record review the facility failed to provide the required supervision to one of two sampled residents (Resident 1). Per facility policy and staff interviews, all mechanical lifts should be operated by two staff. Resident 1 was transferred by one staff using a ceiling lift and this resulted in Resident 1 falling from the ceiling lift.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, Form CMS-10055 (SNF ABN, Form Centers for Medicare & Medicaid Services-10055 - a written notice used to inform the resident/beneficiary of potential financial liability for the non-covered stay and the right to appeal to receive care and services which may not be covered by Medicare) for three of five sampled residents (Resident 59, Resident 60, and Resident 123) receiving Medicare Part A services. This failure had the potential for residents and/or resident representative of not being aware of the financial liability and the right to appeal for the denial or termination of resident's Medicare Part A services.

Inspectors wroteBased on observation, interview and record review, for 26 of 26 sampled residents, the facility failed to ensure residents were able to voice their grievances when the facility failed to implement its grievance policy to address resident rights to file a grievance anonymously. This failure failed to support resident rights to file grievance without discrimination, reprisal or the fear of discrimination or reprisal.

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure that safe food and sanitary condition were met for food storage and dishwashing equipment in the Nutrition Services Department, when expired and unlabeled food items were stored in the refrigerator, dry food storage area and brown stains were found inside the door of the dishwashing machine. These deficient practices have the potential to result in food borne illness for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified social worker was employed on a full-time basis. This failure had the potential to result in residents not receiving sufficient and appropriate coordination of medically related social services to meet the resident's needs. (Refer to F742)

Inspectors wroteBased on interview and record review, the facility failed to implement its plan of action to correct the identified deficiency regarding the social worker's qualification during the recertification survey conducted on 3/4/19 through 3/12/19. This failure resulted in a repeated noncompliance to F850 which had the potential to affect the resident's need for sufficient and appropriate coordination of medically related social services. (Refer to F850 and F742)

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that drugs were labeled in accordance with currently accepted professional principles, and include cautionary instructions, and the expiration dates. This failure had the potential to result in significant unsafe, and adverse consequences that will put the resident's health at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's infection prevention and control program for two (2) of 26 sampled residents when: 1. Wound Nurse (WN) 1 did not complete hand hygiene during Resident 69's wound care treatment. 2. Resident 34's oxygen cannula was found on the floor uncovered. This deficient practice will result in potential spread of infection.

Inspectors wroteBased on observation, interview and record review, for one of 26 sampled residents (Resident 69), the facility failed to implement its policy and procedure to prohibit neglect when multiple reports of allegation of neglect reported by Resident 69's responsible party (RP1) were not investigated. Failure to investigate allegation of neglect prevents timely protection of residents safety and well-being. Definition: Neglect - as defined §483.5, means the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two of 26 sampled residents (Resident 29 and Resident 34) when: 1. There was no care plan addressing the behavioral manifestations and the use of psychotropic medication (drugs used to treat psychiatric conditions) for Resident 29. 2. There was no care plan addressing oxygen therapy use for Resident 34. This failure had the potential to result in inappropriate and inaccurate provisions of care that will impact the quality of care and services for Resident 29 and 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an updated discharge plan for one of one sampled residents (Resident A) when: 1. Resident was not informed about the outcome of the independent housing application and 2. Discharge care plan was not updated to reflect resident's discharge goal. This failure could lead to unnecessary delays in Resident A's discharge or transfer.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 69) received treatment and care in accordance with professional standards of practice. This failure could negatively impact to Resident 69's physical, mental and psychosocial needs.

Inspectors wroteBased on interview, and record review, the facility failed to provide behavioral health services and individualized care approaches addressing the emotional and psychosocial needs for one of 53 residents (Resident 29) receiving psychotropic medications (drugs used to treat psychiatric conditions) when: 1. Psychiatric evaluation was not coordinated after two missed appointments on 2/5/21 and 2/9/21. 2. There was no individualized care plan addressing the behavioral manifestations and the use of psychotropic medication. This failure resulted in Resident 29 not receiving the necessary behavioral health services; and the potential to not attain the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for Resident 115, Resident 126, and Resident 37. This deficient practice resulted in medications not given in accordance to the prescriber's orders and/or manufacturer's specifications which may result in residents not receiving the full therapeutic effect of the medications.