Barton Hospital D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to meet State licensure requirements for Staff Development -Confidentiality of patient information as outlined in the California Code of Regulations, Title 22 when they failed to effectively provide an ongoing educational program to ensure staff possess the necessary skills and knowledge regarding the confidentiality and appropriate use of Protected Health Information (PHI). This failure resulted in a staff member accessing hospital records out of personal interest, not for patient care purposes and the breach of PHI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that wheelchairs were maintained in safe condition when found with cracked and exposed armrest for three of 13 sampled residents (Resident 13, Resident 30, and Resident 43). This failure had the potential to place Resident 13, Resident 30, and Resident 43 at risk for injury and infection. A review of Resident 13's admission Record (AR), dated 4/10/26 (print date), indicated Resident 13 was admitted in Winter 2023 with the diagnoses which included right artificial hip joint (replaced joint for damaged hip), polymyalgia rheumatica (severe stiffness of neck, shoulders and hips), and chronic pain. A review of Resident 13's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/30/26, the MDS indicated Resident 13 had no memory impairment and was dependent on a wheelchair and walker. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the administration time for morphine (a narcotic controlled medication) on the Medication Administration Record (MAR) matched with the Controlled Drug Record (CDR - a log used to track the administration and disposition of Schedule II drugs, substances with a high potential for abuse) for one of 13 sampled residents (Resident 5). This failure resulted in inconsistency in morphine administration for Resident 5 and had the potential to impact accountability of the controlled drug. A review of Resident 5's admission Record indicated she was admitted to the facility in 2022, with diagnoses that included chronic pain and osteomyelitis (a serious infection in the bone, caused by bacteria or fungi, resulting in inflammation and tissue damage, and is often very painful). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in accordance with professional standards for a census of 45, whenAn expired bottle of carboxymethylcellulose sodium 0.5% solution (artificial tears eye drops for dry eyes) was still being administered to Resident 17;An open tube of hydrocortisone cream 1% (a topical steroid used to reduce inflammation and itching caused by conditions like allergic rashes) for general resident use was found without an open date; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety for a census of 45, when:1. Food items were found expired and with no open dates in the resident's refrigerator and2. Crumbs and debris were found in clean and sanitized areas in the kitchen. These failures had the potential to cause food-borne illnesses to a vulnerable population.1. During an observation on 4/8/26 at 4:45 p.m., of the resident's refrigerator, the following was noted: a. one-gallon plastic bag full of expired individual butters (expiration date 3/20/26); b. one bottle of cranberry cocktail juice with an open date of 12/10/25; c. one opened bottle of cranberry juice, undated and unlabeled (no resident's name and no open date and expiration or used-by date); and d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain electrical equipment in a safe condition for a census of 45 residents, when the facility did not routinely remove lint buildup from the dryer in the laundry room. This failure had the potential to affect residents' safety due to fire hazard. During a tour of the laundry room on 4/9/26 at 2:45 p.m., accompanied by Infection Prevention Nurse (IP), a thick layer of lint accumulation was observed in the lint trap compartment of the dryer. The IP stated the lint trap was to be cleaned on a regular basis to remove lint accumulation and validated that lint compartment had accumulated lint. The IP was unable to provide documentation or a log confirming routine lint removal from lint compartment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST, a form signed by the resident or representative and physician, outlining specific treatment wishes and end-of-life preferences) was signed by Public Conservator (PC, a legally recognized and authorized surrogate decision maker) for one of 13 sampled residents (Resident 33), when Resident 33's POLST form indicated Do Not Resuscitate (DNR) status, but lacked the required name and signature of PC.This failure had the potential for Resident 33 not to receive treatment and care in the event of a medical emergency and deprived the resident's Public Guardian ability to make informed decisions affecting Resident 33's care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' confidentiality was maintained for one resident (Resident 52) for a census of 45 when a computer screen was open and unattended by staff; publicly displaying Resident 52's private medical information. This failure decreased the facility's ability to protect Resident 52's private health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's order was followed for one of 13 sampled residents (Resident 7), when monthly weights were not obtained as ordered. This failure had the potential risk for Resident 33 to have unrecognized weight loss. A review of Resident 7's admission Record indicated Resident 7 was admitted in Fall 2024 with the diagnoses which included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and Crohn's Disease (an immune disorder where the immune system attacks healthy gut tissue). A review of Resident 7's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/12/26, the MDS indicated that Resident 7 did not have the capacity to make decisions and was at risk for weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide standard quality care to one resident (Resident 4) of a sample of 13 when catheter placement and care were not included in Resident 4's care plan, orders, treatment record, and urine output log. This failure increased the potential for Resident 4 to get a urinary tract infection (UTI - an infection caused by bacteria entering the urinary tract, including the bladder and kidneys) and be readmitted to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychotropic medications (medications that affect mood and behavior) were administered in accordance with acceptable standards of practice for one of 13 sampled residents (Resident 6), when Resident 6 was administered Citalopram (an antidepressant medication) without documentation of a diagnosis of depression or other clinically appropriate indication for use. This failure placed Resident 6 at risk for unnecessary exposure to psychotropic medications and potential adverse effects (unwanted, uncomfortable, or dangerous effects) related to the use of Citalopram. A review of the admission record indicated the facility admitted Resident 6 in 2024 with multiple diagnoses which included high blood pressure, diabetes mellitus (elevated blood glucose), and fracture of right upper arm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent an avoidable fall accident for one of three sampled residents (Resident 1), who was identified at high risk for falls. This failure resulted in Resident 1 falling, hitting his head and fracturing his right femur (thighbone), causing severe pain, and transfer to the hospital. Resident 1 was placed on comfort care in the hospital and died on [DATE], 3 days after the fall incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and evaluate the resident's clinical condition and risk factors for developing urinary tract infection (UTI, an infection in the bladder and urinary tract) for one of 5 sampled residents (Resident 1), when the resident experienced weakness and difficulties with urination. This failure had the potential to delay the provision of care and treatment for Resident 1 and placed the resident at risk for unnecessary pain and emotional distress. A review of the admission Record indicated the facility admitted Resident 1 in early 2025 with multiple diagnoses which included history of prostate cancer (cancer of the prostate gland, located below the bladder) and acute kidney failure (AKF, a condition when kidneys fail to filter waste and extra water suddenly potentially causing health problems; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two residents (Resident 1 and Resident 2) from abuse, when the staff witnessed Resident 1 hitting Resident 2 in the head and Resident 2 grabbing Resident 1's forearm. In addition, the facility failed to assess and document Resident 1's skin injury and the treatment that was provided. This failure resulted in Resident 2 being hit on the head and Resident 1 receiving skin tears to right forearm and had the potential to result in emotional distress for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision when staff left Resident 1 unattended to prevent an avoidable accident from occurring for 1 of 3 sampled residents (Resident 1). This failure resulted in Resident 1 falling and sustaining a hip fracture (broken bone).

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 hit Resident 1 on the face as witnessed by Resident 2 ' s one-on-one sitter. This failure reduced the facility's potential to protect Resident 1's right to be free from physical abuse and had the potential for Resident 1 to suffer physical and emotional injury.

Inspectors wroteBased on interview and record review, the facility failed to respond in a timely manner to a medication irregularity for one of 16 sampled residents (Resident 8), when the facility did not follow up on a Pharmacy Consultant (PC) recommendation to discontinue nitrofurantoin (antibiotic, a medication to treat infections) for 56 days. This failure placed Resident 8 at an increased risk for developing adverse drug consequences (unwanted, uncomfortable, or dangerous effects) from the prolonged use of an antibiotic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain mobility and prevent further decrease in range of motion for two of 16 sampled residents (Resident 22 and Resident 34), when: 1. Resident 22's physician's order and care plan's interventions for the management of his left arm weakness and left hand contracture (shortening and hardening of muscles and ligaments leading to deformity, rigidity of joints, and loss of motion) were not followed, and 2. Resident 34 did not receive restorative nursing assistant (RNA, exercises to improve or maintain resident's functional abilities) services consistently per physical therapy (PT) recommendations and her care plan's interventions. These failures placed Resident 22 and Resident 34 at risk for further complications and decline in their physical functioning and mobility.