Beach Creek Post-Acute

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the resident's physician and resident's representative of a change in condition for one of six sampled residents (Resident 4). * The facility failed to notify Resident 4's physician and resident's representative of the resident's unwitnessed fall timely. This failure had the potential to result in Resident 4 not receiving timely and appropriate care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of six of final sampled (Residents 1, 2, 6, 9, 121, and 131) and five non-sampled residents (Residents 24, 26, 52, 66, 115) reviewed for respiratory care. * The facility failed to administer oxygen to Resident 24 per the physician's order. * The facility failed to administer oxygen to Resident 66 per the physician's order. In addition, the facility failed to ensure the set-up bag for the nasal cannula for Resident 66 was changed every seven days. * The facility failed to ensure the nasal cannula tubing and oxygen concentrator near Resident 2's bed was hers and not her roommate's. In addition, the facility failed to ensure the set-up bag for the nasal cannula for Resident 2 was changed every seven days. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment was in good condition. *The facility failed to ensure a dented can was removed. *The facility failed to ensure the resident food refrigerator was clean. * The facility failed to ensure the chlorine strips for the low-temperature dishwashing machine had not expired * The facility failed to air dry the blender prior to the puree preparation. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure seven of seven final sampled residents (Residents 1, 3, 6, 8, 10, 68, and 121) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 10's orthostatic BP was monitored for the use of the olanzapine (antipsychotic medication); and failed to ensure the nonpharmacological interventions and its effectiveness were documented for the documented observed behaviors related to the use of the olanzapine, hydroxyzine (antihistamine) and Ativan (antianxiety) medications. * The facility failed to ensure Resident 68's orthostatic BP was monitored for the use of the aripiprazole (antipsychotic medication); [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the quality care and services were provided for one of one final sampled resident (Resident 31) reviewed for hospitalization. * The facility failed to provide necessary care when Resident 31's blood pressure was 76/51 mmHg. This failure had the potential for Resident 31 to not receive the necessary care and services to maintain their highest physical well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of two final sampled residents (Resident 135) reviewed for pressure injuries. * The facility failed to reposition Resident 135, who had a pressure injury, at least every two hours as addressed in Resident 135's plan of care. This failure had the potential for Resident 135 to develop pressure injuries or worsening of the existing pressure injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents remained free from accident hazards for two of 27 final sampled residents (Residents 14 & 22). * The facility failed to implement the bilateral floor mats as per the physician's order and plan of care for Residents 14 and 22. These failures had the potential to place Residents 14 and 22 at risk for serious injuryFindings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. On 1/22/26 at 0851, 0951 and 1021 hours, Resident 14 was observed lying in bed and had one floor pad positioned on the left side of the bed. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for three of three final sampled residents (Residents 3, 8, and 10) reviewed for pain management. * The facility failed to administer the pain medication according to the physician's orders for Resident 8. In addition, the facility failed to ensure the nonpharmacological interventions were provided to Resident 8 prior to the administration of the pain medication. * The facility failed to ensure the hydrocodone-acetaminophen (narcotic pain medication) pain medication was administered per the physician's orders for Resident 10. In addition, the facility failed to ensure non-pharmacological interventions were provided to Resident 10 and documented prior to the administration of the PRN hydrocodone-acetaminophen and Tylenol medications. [...]

Inspectors wroteBased on interview, and medical record review, the facility failed to accurately monitor the fluid intake and output for one of two final sampled residents (Resident 145) reviewed for hemodialysis care. * The facility failed to ensure Resident 145's fluid intake and output was accurately monitored. This failure had the potential for Resident 145 to not be provided with the appropriate care and treatment, and to experience life threatening conditions associated with fluid deficit/overload.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 27 final sampled residents (Residents 6 and 10) were free from the unnecessary medications. * The facility failed to ensure Resident 10's carvedilol (blood pressure medication) was administered as per the physician's order. * The facility failed to ensure Resident 6's pulse was monitored prior to the administration of the atenolol (blood pressure medication). These failures had the potential for Residents 6 and 10 to receive unnecessary medications and develop significant adverse effects related to the use of the medications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services. * The facility failed to ensure orally administered medications were stored separate from the externally used medications in Medication room [ROOM NUMBER]. *The facility failed to ensure the expired supplies were removed from the current treatment supply in Treatment Cart A. * The facility failed to ensure there were no medications left at bedside. * The facility failed to ensure RN 4 and LVN 7 did not leave medications on top of medication cart during medication pass observation. * The facility failed to ensure a medication cup with white paste was not left on Resident 1's overbed table. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menu to meet the resident's nutritional needs was followed for one of 85 residents (Resident 82) who received food from the kitchen. * The facility failed to ensure Resident 82 was served the corn on the cob or street corn, as per the menu. Resident 82 was served green beans. This failure posed the risk for negatively impacting the residents' satisfaction and dietary compliance.

Inspectors wroteBased on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to ensure the food preference was honored for one of 27 final sampled residents (Resident 3). * The facility failed to ensure Resident 3 was served white bread per the resident's meal ticket. This failure had the potential for the resident to not receive a meal to meet the resident's needs and preferences.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to accommodate the drink preferences for one of 27 final sampled resident (Resident 111). * The facility failed to ensure Resident 111 was served two milk cartons, as per the meal ticket, for his lunch meal. This failure had the potential to affect the resident's overall meal intake and nutritional status.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the garbage and refuse were properly stored for one of three dumpsters. * The facility failed to ensure one of three dumpster's lid was fully closed. This failure had the potential to attract pests and rodents that carried diseases.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medical records were accurately completed for four of 27 final residents (Residents 3, 5, 8 and 135). * The facility failed to ensure Resident 3's MAR for [DATE] was completed and signed. * The facility failed to ensure Resident 5's POLST Section D was completed. * The facility failed to ensure Resident 135's POLST Section D was completed. * The facility failed to ensure Resident 8's POLST Section D was completed. These failures posed a potential risk for residents to not be provided with the care and treatment since their medical record information was incomplete.

Inspectors wroteBased on interview and facility document review, the facility failed to implement their QAPI plan of action. * There was no documentation to show the facility had provided an in-service for medication storage, specifically storing internally administered medication separately from externally administered medications for one repeated deficient practice cited at F761 in accordance with their POC from the last recertification survey completed on 1/9/25. This failure had the potential for medication errors and negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's advanced directive was obtained and maintained in the medical record for one of 27 final sampled residents (Resident 3). * The facility failed to ensure the advanced directive copy for Resident 3 was available in the resident's medical record. This failure had the potential for the resident's decisions regarding their healthcare and treatment options to not be honored.

Inspectors wroteBased on interview, and medical record review, the facility failed to provide the NOMNC and the SNF ABN Form CMS-10055 to one of three final sampled residents (Resident 100) reviewed for beneficiary notification. * The facility failed to ensure Resident 100 was provided with the NOMNC and SNF ABN forms before Resident 100's last covered date of 10/8/25. The NOMNC and SNF ABN forms were signed by Resident 100's representative on 1/26/26. This failure had the potential of not allowing Resident 100 and his representative to make an informed decision regarding their Medicare services and to understand their financial responsibilities and options concerning their medical care.

Inspectors wroteBased on interview and medical record review, the facility failed to transmit the MDS assessment timely for one of one non-sampled resident (Resident 116) reviewed for resident assessments. * The facility failed to transmit Resident 116's Discharge MDS assessment within 14 days of the completion date. This failure caused a delay in providing resident specific information for payment and quality measure purposes to CMS.

Inspectors wroteBased on interview and medical record review, the facility failed to complete the MDS assessment accurately for one of three sampled residents (Resident 142) reviewed for closed records. * Resident 142's MDS assessment showed the resident was discharged to the acute care hospital when Resident 142 was discharged home. This failure resulted in inaccurate resident data used for quality measure purposes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive resident-centered plan of care for one of 27 final sampled residents (Resident 22). * The facility failed to develop a care plan problem to address Resident 22's refusal to use the bedside commode. This failure had the potential for Resident 22 not to receive adequate and individualized care to support safety and well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure appropriate medication administration. * The facility failed to ensure LVN 6 checked whether Resident 131 had loose stools prior to to the administration of Glycolax (laxative medication) * The facility failed to clarify the route of medication administration for Resident 121. These failures created the risk for the residents to have potential side effects or complications related to the use of medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infection. * The facility failed to ensure the clean area of the laundry room was free from clutter when there was a pen holder with pens and pencils and a box of tissue. This failure had the potential for cross contamination and cause negative impact to the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain essential equipment in proper working and sanitary condition. * The facility failed to ensure Resident 131's tube feeding pole was free from brownish rust like areas. This failure had the potential for the equipment to not function the way it was intended.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the abuse investigation protocol was followed for one of three sampled residents (Resident 1) reviewed for abuse. * The facility failed to ensure CNA 1 was suspended immediately when Resident 1 reported to the facility staff of allegation of abuse against CNA 1. Resident 1 reported CNA 1 being rough during the provision of care. * The facility failed to report the result of the investigation to the CDPH, L&C Program, Orange District Office within five working days. These failures had the potential to put vulnerable residents at increased risk for abuse and/or delay in providing the necessary care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan for one of 27 final sampled residents (Resident 13). * Resident 13's At Risk for Respiratory Distress care plan showed to administer the oxygen as ordered by the physician (a rate of two liters per minute); however, Resident 13 was receiving oxygen at a rate of four and a half liters per minute. This failure posed the risk for not providing appropriate an individualized care to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (final sampled, Resident 13) reviewed for respiratory care, was provided with the appropriate respiratory care when: * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 13. This failure had the potential to result in negative health outcomes for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest well-being for one of three residents (final sampled resident, Resident 106) reviewed for hemodialysis (treatment to remove waste and extra fluid from the blood using a filtering machine). * The facility failed to monitor Resident 106's fluid restriction as per the physician's order. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmacy services as per the facility P&P for four nonsampled residents (Residents 63, 77, 85, and 118). * LVN 6 failed to ensure Residents 63 and 77's scheduled morning medications (at 0900 hours) were administered timely within 60 minutes of the scheduled time. * The facility failed to ensure the accurate and complete documentation of the controlled medications administered to Resident 85. * The facility failed to ensure the administration of the controlled medication for Resident 118 was documented in the narcotic and hypnotic record. These failures had the potential to place the residents at risk for delays in treatment and increased risk for adverse events and posed the risk for diversion of medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8.33%. * Resident 4 had a physician's order for vitamin B12 5000 micrograms orally to be administered one time a day for supplement; however, the LVN administered vitamin B12 1000 micrograms to Resident 4. In addition, the LVN applied a nicotine 21 mg transdermal patch to Resident 4's lower back; however, Resident 4 did not have a physician's order for a nicotine transdermal patch. * Resident 63 had a physician's order for a multi-vitamin/minerals tablet to be administered orally for supplement; however, the LVN administered a multi-vitamin without minerals to Resident 63. These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the orally administered medications were stored separately from the rectally administered medication in Medication Cart 5. * The facility failed to ensure the medication drawer was kept clean and free of dried white residue in Medication Cart 5. * A package which contained nicotine 21 mg transdermal patches was not labeled with a resident's name, prescribing physician's name, prescription number, or prescribed dose. Subsequently a LVN applied the nicotine 21 mg transdermal patch to a resident (Resident 4) without a physician's order for the nicotine 21 mg transdermal patch. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen when: * The facility failed to ensure the ice machine was maintained in a sanitary condition. * The facility failed to ensure the raw meat was stored in a sanitary manner. * The facility failed to ensure the kitchen equipment was clean. These failures posed the risk for food borne illnesses in highly susceptible resident population of 125 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: * CNA 1 did not follow the EBP when providing incontinence care for Resident 58. * The facility failed to ensure the CNA donned the appropriate PPE when providing care to Resident 50. * There was no receptacle readily available to discard used gowns for the resident on EBP. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. This failure posed the threat for pest contamination.

Inspectors wroteBased on interview and facility document review, the facility failed to conduct and document a facility-wide assessment to determine the resources necessary to care for its residents competently during both day-to-day operations and emergencies. This failure posed the risk of the facility not being able to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents required.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of nonsampled resident (Resident 51) had accurate and complete medical records. * The facility failed to ensure Resident 51's Pulmonary administration were documented as ordered. This failure had the potential for the resident's health care needs to not be met as the medical record was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for two of five sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1 received oxygen 2 liters per minute via nasal cannula as per the physician's order. In addition, the facility failed to ensure the nebulizer (used to deliver vaporized medicine into the airway) mask was stored properly. * The facility failed to ensure Resident 2's nebulizer mask and BiPAP (bilevel positive airway pressure, a machine used to provide pressurized air into the airways while asleep) mask were stored properly. These failures had the potential to affect the residents' health and well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. * The facility failed to ensure the robot coupe blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the silver metal chopper was clean and free of food particles. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and not worn out. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to one of 26 final sampled residents (Resident 34). Resident 34 had a bottle of inhalant, decongestant observed at the bedside. This failure had a potential to negatively impact the resident's physiological well-being, and administer medications inaccurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow the policy for advance directives for two of 26 final sampled residents (Residents 34 and 50). * The facility failed to obtain a copy of the advance directive for Resident 50. * The facility failed to to ensure an assistance was provided to formulate an advance directive for Resident 34. These had the potential for the resident's decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean home-like environment for one of 26 final sampled residents (Resident 50). Resident 50's floor fan in her room was observed with dust build-up on the vents of the fan. This placed the resident at risk for living in an unkempt environment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled residents (Resident 103) was free from unnecessary restraints. * Resident 103 was diagnosed with dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and had behaviors of hitting, kicking, pushing, scratching, and grabbing directed towards others. Resident 103's bottom portion of the top sheet was observed tied down onto the low air loss mattress straps in a manner which restricted Resident 103's ability to freely move his legs. * The facility utilized an abdominal binder on Resident 103. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop and implement the comprehensive person-centered care plans for three of 26 sampled residents (Residents 6, 38, and 95) and one nonsampled resident (Resident 103). * The facility failed to develop the care plan problem for the use of floor padding for Resident 38 who was at high risk for falls. In addition, Resident 38's care plan problem showed Resident 38 should be provided with two-person assistance for transfers; however, Resident 38 was transferred with the assistance of one person from her wheelchair to her bed. * The facility failed to develop the care plan problem for the use of abdominal binder for Resident 103. * The facility failed to ensure the care plan problem for Ativan use for Resident 6 was specific and individualized. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was revised to reflect specific care needs for one of 26 sampled resident (Resident 50). This failure posed the risk for not providing the resident with individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to implement the safety interventions and provide the padded side rails for one of 26 sampled resident (Resident 87) who had a diagnosis of seizure disorder (neurological disorder causing sudden, uncontrolled burst of electrical activity in the brain that leads to convulsions or uncontrollable shaking that is rapid and rhythmic). This failure put Resident 87 at risk for serious injuries during a seizure episode.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 50 and 87) and one nonsampled resident (Resident 103) who received enteral (refers to the intake of food through a gastrostomy tube) feeding were provided appropriate treatment and services to prevent complications of the enteral feeding. * The facility failed to ensure Resident 87 was administered the enteral feeding at the infusing rate as ordered by the physician. * The facility failed to ensure Residents 87 and 103's head of bed elevated when administering the enteral feeding. * The facility failed to ensure the enteral feeding mechanical pump was operated by a licensed staff while providing care for Residents 50 and 103. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for two of 26 final sampled residents (Residents 34 and 95). * The facility failed to follow the physician's order for the administration of continuous oxygen for Resident 95. Resident 95 had an order to receive continuous oxygen at 2 liters per minute; however, Resident 95 received continuous oxygen at 4 liters per minute. * The facility failed to label the oxygen tubing for Resident 34. These failures had the potential to negatively impact Residents 34's and 95's medical conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 26 final sampled residents (Resident 34). * The facility failed to ensure the dialysis shunt site (a passage made to allow blood or other fluid to move from one pat of the body to another) was monitored every shift and documented in the medical record. * The facility failed to ensure the pre and post dialysis communication forms were completely filled out. * The facility failed to ensure the physician's order for a 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the accurate administration and documentation of the controlled medications (medications that have some potential for abuse or dependence) for one nonsampled resident (Resident 104). This failure had the potential for exposing residents to ineffective treatment, medication errors, and the potential for diversion of controlled medications.

Inspectors wroteBased on interview, medical record review, and P&P review, the facility failed to follow their P&P for drug regimen review for one of 26 final sampled residents (Resident 55) and one nonsampled resident (Resident 66). * The facility's Pharmacy Consultant made multiple recommendations on the Medication Regimen Review (MRR) reports for Residents 55 and 66; however, the facility failed to follow up on the recommendations for the month of January 2023. This failure put the residents at risk for complications and adverse effects from the medications.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of five unnecessary medication sampled residents (Residents 55 and 66) were free from unnecessary drugs. * The facility failed to monitor for signs and symptoms of bleeding related to Resident 55's use of Pradaxa (medication used to treat and prevent blood clots). * The facility failed to ensure Resident 66 was free from duplicate therapy as two antiulcer medications (famotidine and omeprazole) were ordered without evidence or a documented clinical rationale. These failures had the potential for the residents to receive unnecessary medication and develop significant side effects.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of five unnecessary medication sampled residents (Residents 6 and 55) free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior). * For Resident 6, the Ambien PRN order did not have specific duration and exceeded 14 days without prescriber-documented rationale for extending the medication duration. There was no nonpharmacological interventions prior to Ativan use and no physician's clinical rationale documented for renewing the Ativan (antianxiety medication) PRN order. In addition, there were no side effect monitoring for the use of psychotropic medications. * For Resident 55, the clinical rationale for not attempting gradual dose reduction (GDR) for psychotropic medications were not documented. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and medical record review, the facility failed to ensure the medication error rate was less than 5%. The facility's medication error rate was 12.5%. * LVN 1 failed to administer Symbicort (bronchodilator) and ferrous sulfate (supplement) for Resident 40 as per the physician's order. * LVN 2 failed to administer vitamin C (supplement), vitamin D, and aspirin to Resident 112 as per the physician's order. These failures had the potential to expose the residents to significant adverse reactions and complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * Multiple opened medications containers with no open dates were observed in Medication Cart 1. * Two discontinued unopened medication bottles of Lactulose (medication used to treat constipation or high levels of ammonia in the blood) oral solution were stored in Medication Cart 1 instead of being disposed. * Multiple missing temperature log entries were observed in the refrigerator temperature log book in Medication room [ROOM NUMBER]. * One IV E-Kit with opened date [DATE], was observed in Medication room [ROOM NUMBER]. * Expired wound care supplies were observed in Treatment Cart 2. * Expired IV supplies were observed in the IV Cart. * Expired sunscreen and inhaler medications were observed in the TRC Medication Pass Cart. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure the Monthly Infection Surveillance Reports were completed. For example, the information such as the residents' symptoms of infection, type of organisms when a culture was obtained, when the antibiotic was ordered, the duration of the antibiotics, and any laboratory/diagnostic tests were not documented. This had the potential for the antibiotics used were not indicated and the development of the antibiotic resistant bacteria. * The facility failed to ensure the Sani Hands wipes used on the residents had not expired. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain the antibiotic stewardship program designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to identify CAIs and HAIs and failed to address the use of antibiotics for residents whose symptoms did not meet the McGeer's Criteria in the infection control meeting for one final sampled resident (Resident 38). These failures posed the risk of inaccurately identifying if the residents met the criteria for a true infection and inappropriate antibiotic usage.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the foot panel attached to the resident's bed was assembled in accordance with the bed manufacturer's User-Service Manual for one of 26 final sampled residents (Resident 24). * Resident 24's bed foot panel was observed to be loose as evidenced by moving back and forth. Upon inspection by the Maintenance Director, it was determined the foot panel was not attached to the bed as per the bed manufacture's User-Service Manual. This failure posed the risk for entrapment between the bed foot panel and bedframe and/or mattress, potentially causing serious injury to the resident.

Inspectors wroteBased on interview, the facility failed to ensure eight of eight residents interviewed (Residents 15, 33, 35, 58, 62, 66, 72, and 106) knew how to contact the California Department of Public Health to file a complaint. This posed the risk of the residents not knowing how to contact the state should the residents require the state services.