Brighton Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness) by failing to ensure shower chair wheels were locked for one (1) of two (2) sampled residents (Resident 1) while using the toilet. These deficient practices have resulted in Resident 1 to fall on 3/11/2026 while the reisdent is using the toilet and had the potential to result in serious injury like fractures (break in bone), intracranial hemorrhage (a life threatening, acute bleeding within the skull, often referred to as brain bleed or brain hemorrhage), prolonged hospitalization, and/ or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary respiratory care services for two (2) of three (3) sampled Residents ( Residents 102 and 13) reviewed for oxygen (O2, a highly reactive, colorless, odorless gas vital for life) as indicated in the facility policy by failing to:Provide Resident 102 a new humidifier (a device used to add moisture to dry oxygen, reducing irritation in the nose and throat for residents during oxygen therapy) when it was empty on 1/26/2026. Administer Resident 13's oxygen as indicated on the physician's order. These deficient practices have the potential for Residents 102 and 13 to develop respiratory complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for six (6) of 10 sampled residents (Residents 95, 64, 24, 82, 15, and 109) reviewed and observed for medications administration, in accordance with the facility's policy and procedure (P&P) by failing to: 1. Administer metformin (medication used to control high blood sugar levels) and potassium chloride (medication used to regulate the heartbeat) within 60 minutes of the scheduled time of 7:15 AM for Resident 95. This deficient practice had the potential for Resident 95 to experience chest pain, shortness of breath, dizziness, and placed Resident 95 at risk for inadequate blood sugar management which could cause hyperglycemia (elevated blood sugar level).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Eight (8) medication errors (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 29 opportunities (observed administered medications) for error which yielded a facility medication error rate of 27.59% for four (4) of 10 sampled residents (Residents 95, 64, 24, and 82) observed for medication administration (med pass). Licensed Vocational Nurse 1 (LVN 1) failed to administer metformin (medication used to control high blood sugar levels) and potassium chloride (medication used to regulate the heartbeat) within 60 minutes of the scheduled time of 7:15 AM for Resident 95. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) of 10 sampled residents (Resident 95, 64, 24, and 82) were free from significant medication errors by facility to:1. Administer metformin (medication used to control high blood sugar levels) and potassium chloride (medication used to regulate the heartbeat) within 60 minutes of the scheduled time of 7:15 AM for Resident 95. This deficient practice had the potential for Resident 95 to experience chest pain, shortness of breath, dizziness, and placed Resident 95 at risk for inadequate blood sugar management which could cause hyperglycemia (elevated blood sugar level). 2. Administer metoprolol tartrate (a medication used to treat high blood pressure) within 60 minutes of scheduled time of 7:15 AM for Resident 64. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and sanitary storage and handling of food brought in by resident's family or other visitors in accordance with the facility's policy and procedure (P&P) titled Food Brought in by Family/Visitors when: 1. Three (3) unopened Ensure drinks (nutrient-dense, ready-to-drink meal replacements designed to provide protein, vitamins, minerals, and calories for individuals needing extra nutrition) were not labeled with the resident's name 2. One (1) opened apple juice bottle was not labeled with use-by date (the date up until which a food may be used safely).3. Staff food item and an unlabeled container with food (unknown if for resident or staff) were stored in the designated refrigerator for residents' use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for four of 19 sampled residents (Residents 5, 49, 105, 9 and 95) as indicated on the facility policy by failing to ensure:Treatment Nurse 1 (TN 1) performed hand hygiene (washing hands with soap and water for at least 20 seconds, or using alcohol-based sanitizer, to effectively eliminate germs and prevent disease spread) after removing a soiled wound dressing for Resident 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic (type of medication that kills or inhibits the growth of bacteria) surveillance (the continuous tracking and analysis of how antibiotics are used and how bacteria are becoming resistant to them) data collection form was completed for two (2) of three (3) sampled residents (Resident 5 and 106) reviewed for antibiotic in accordance with the facility policy. This deficient practice had the potential for the residents to be prescribed inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics).

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 8) reviewed for beneficiary notification was not provided with the Skilled Nursing Facility (SNF) Beneficiary Notification form (also called the Skilled Nursing Facility Advance Beneficiary Notice of Non coverage Form, a Medicare [federal health insurance program] - required notice provided to Medicare beneficiaries when Medicare payment is expected to be denied for certain services or items) in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in Resident 8 not being able to exercise the resident's right to file an appeal and cause stress to the resident for inability to make adequate arrangements for charges that may be incurredFindings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to secure and provide confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of medical records for one (1) of 1 sampled residents Resident 85) reviewed for privacy when Resident 85's wound treatment order was left exposed when Computer 1's (COM 1) screen was left open and unattended on 1/27/2026. This deficient practice violated Resident 85's right to privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure to ensure an allegation of physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to California Department of Public Health (CDPH), local law enforcement, and Ombudsman (an official appointed to investigate individuals' complaints against the facility) within two (2) hours for one (1) of 1 sampled residents (Resident 8) reviewed for abuse. This deficient practice had the potential to under report allegations of abuse and placed Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a coordination for a Level II Preadmission Screening and Resident Review Assessment (Level II PASRR, comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has mental disorder [MD], intellectual disability [ID] or a related condition, and determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs) was completed within 24 hours for a resident with a positive (individuals who have or are suspected to have MD, ID or a related condition) Level 1 PASRR (initial screening for possible serious MD, ID, and related conditions) for one (1) of three (3) sampled residents (Resident 60) reviewed for PASARR, in accordance with the facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of 19 sampled residents (Resident 19 and Resident 24) received treatment and care in accordance with its Policy and Procedure (P&P) by failing to:Assess and obtain treatment for Resident 102's itch and peeling skin. Assess and obtain treatment for Resident 7's thick, brittle, and discolored nails. This deficient practice has the potential to cause complications such as infection and hospitalization of Residents 102 and 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for one (1) of 1 sampled residents (Resident 60) reviewed for catheter (indwelling catheter, tube inserted into the bladder to drain urine into a drainage bag) by failing to assess, monitor, and document signs and symptoms (s/sx) of urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder [organ that stores urine] or urethra [the tube through which urine leave the body]) as indicated in the physician's order and care plan and to keep the indwelling catheter bag off the floor as indicated in the facility's Urinary Catheter Care Policy and Procedure (P&P). These deficient practices had the potential to result in delayed UTI identification, delayed treatment, worsening infection, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 60) reviewed for tube feeding (gastrostomy tubes [GT- a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration]) receive appropriate treatment and services by failing to properly label Resident 60's GT formula bag with licensed nurse's initials, date, and time the formula was hung/administered as indicated on the facility policy. This deficient practice placed Resident 60 at risk for not receiving the correct tube feeding and amount per physician's order, which could lead to complications such as weight loss and fluid overload (an excess of fluid in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for one (1) of 1 sampled resident (Resident 11) reviewed for dialysis (the medical necessity for ongoing removal of waste and excess fluid from the blood to sustain life due to permanent kidney failure) by failing to:Monitor Resident 11's fluid intake weekly and follow the physician's order for fluid restriction of 1200 milliliters (ml- unit of measurement for volume) a day. Develop a resident-centered comprehensive care plan (a care plan developed and implemented to meet the resident's preferences and goals, and addresses the resident's medical, physical, mental, and psychosocial needs) for Resident 11 who was on fluid restriction. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to refrigerate one unopened insulin (a hormone made by the pancreas [sits behind the stomach in the upper abdomen that plays a key role in both digestion and blood sugar regulation] that acts like a key so it can be used for energy, effectively lowering blood sugar levels after eating) vial for Resident 108, in accordance with the facility policy. This deficient practice increases the risk of Resident 108 receiving a medication that had become ineffective or toxic due to improper storage, possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview and record review, the facility failed provide accurate documentation of treatment done for one (1) of 19 sampled residents (Resident 9) in accordance with professional standards (the expectations, guidelines, and rules that individuals in a particular profession must follow to maintain quality, ethics, and safety in their work) and practices by failing to transcribe physician's order for Resident 9's oxygen administration from Hospice (a program that gives special care to residents who are near the end of life and have stopped treatment to cure or control their disease) agency order to the resident's physician's order in the facility records. This deficient practice had the potential to affect the accuracy of clinical assessments and medical management for Resident 9.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) was provided with a breakfast tray that did not contain food that the resident was allergic to. This failure had the potential to result in Resident 1 experiencing an allergic reaction such as anaphylaxis (a severe, whole-body allergic reaction that happens quickly and can be life-threatening). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within easy reach for one of three (3) sampled residents, (Resident 2). This deficient practice had the potential to cause delay or not able to provide care and services for Resident 2's requests and needs to maintain Resident 2's safety and highest wellbeing. During a review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but not limit to type II diabetes mellitus (a chronic condition that happens when you have persistently high blood sugar levels. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 8/4/2025 for one (1) of two (2) sampled residents (Residents 1) within two (2) hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect the resident's emotional and mental wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions when a resident was wrapping the bed remote cord around his arms for one (1) of two (2) sampled residents (Resident 1). This deficient practice has the potential to delay in the necessary care and services for Resident 1 which resulted in skin discoloration on both arms.

Inspectors wroteBased on interview and record review, the facility failed to report a fall accident that happened on 5/15/2025 accordance of facility ' s policy for one (1) of 2 (two) sampled residents (Resident 1). This failure not only resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to investigate incident of fall, but also lead to delay of prevent further falls to ensure safety of Resident 1 and other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) per facility policy, for one of four sampled residents (Resident 2). These failures had the potential for Resident 2 to receive colostomy care that is not personalized to meet the specific needs identified above, which could result in decreased quality of care and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care for one of four sampled residents (Resident 2) as ordered by the physician. This failure had the potential to result in colostomy complications including discomfort, stool leakage or decreased quality of life for Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care was documented accurately and completely for one of two sampled residents (Resident 2), as indicated in the facility's policy titled, Charting and Documentation,. This failure had the potential to negatively impact the delivery of treatments and care for Resident 2's colostomy.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Residents 1 and 2) were free from falls and injury by failing to: 1.a Ensure Certified Nursing Assistant 2 (CNA 2) did not leave Resident 1 who was assessed to require increased assistance to perform tasks and the resident would benefit from caregiver (facility staff) supervision to decrease fall risk, without facility staff to supervise Resident 1 in the resident's room while the resident is sitting in a wheelchair during breakfast on 3/11/2025 in accordance with Resident 1's Physical Therapy (PT - healthcare profession that focuses on promoting, maintaining, or restoring health through patient education, physical intervention, disease prevention, and health promotion) Recertification (PTR - documentation to ensure continued PT is necessary by documenting progress, justifying medical [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of two sampled residents (Resident 1) who was at risk for falls by failing to ensure Resident 1's Care Plan for High risk for falls was revised on 3/4/2025 to reflect the Physical Therapy (PT - healthcare profession that focuses on promoting, maintaining, or restoring health through patient education, physical intervention, disease prevention, and health promotion) Recertification (PTR - documentation to ensure continued PT is necessary by documenting progress, justifying medical necessity) note to increase assistance to the resident to perform task and caregiver supervision to decrease fall risk. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was addressed in a timely manner (one of the major communication technologies that link nursing home staff to the needs of residents) for one (1) of 3 sampled residents (Resident 2). This deficient practice had the potential to result in a delay in care and services for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming services to one (1) of three (3) sampled residents (Resident 1) who were dependent with activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility ' s policy. This deficient practice resulted in Resident 1 ' s unkempt and dirty fingernails and toenails potentially leading to skin injury, infection, and scarring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) was updated in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential for residents and visitors to not be informed of the facility's census and staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 1's Santyl ointment (ointment used to remove damaged or burned skin) was labeled indicating the Resident 1 ' s name, the route of administration, the medication dose, and the frequency of administration in accordance to the facility ' s policy and procedure titled, Labeling of Medication Containers. This deficient practice had the potential for Resident 1 to not receive medications as ordered or as directed. 2. Ensure medication cart 1 (med cart 1- a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) was kept locked when unattended to prevent unauthorized access in accordance with the facility ' s P&P titled Security of Medication Cart. [...]

Inspectors wrote2. During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), multiple sclerosis (an autoimmune disease that affects the brain and spinal cord with symptoms ranging from numbness and tingling to blindness and paralysis), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of right hand. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, resident-centered care plan was developed for five (5) of 21 sampled residents (Resident 126, 1, 37, 2, and 59) as indicated on the facility's policy: 1. Resident 126 did not have a care plan for the use of oxygen. 2. Resident 1 did not have a care plan for Restorative Nursing Assistant (RNA) services (provided by certified nursing assistants [CNAs] who specialize in rehabilitation and restorative care for residents with limited mobility.) 3. Resident 37 did not have a care plan for the refusal of RNA services. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 59) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the facility's policy and procedure and physician's order by failing to ensure Resident 1 and 59's low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings. This deficient practice had the potential to place Residents 1 and 59 at risk for skin integrity complications and to have worsening or recurrence of a pressure sore.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and 2) who had an indwelling urinary catheter (Foley Catheter, tube inserted into the bladder to drain urine into a drainage bag) received appropriate care and services as indicated in the physician's orders by failing to appropriately assess and document signs and symptoms (s/sx) of urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, bladder [organ that stores urine] or urethra [the tube through which urine leave the body]). These deficient practices resulted in delayed UTI identification, delayed treatment, and had the potential to lead to worsening infection.

Inspectors wrote2. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of dementia (a progressive state of decline in mental abilities) and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated resident was moderately impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. MDS also indicated Resident 16 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, and putting on/taking off footwear. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications per facility policy for two (2) of four (4) sampled residents (Resident 228 and 223) observed during medication administration by failing to: 1. Administer Resident 228's aspirin (a type of nonsteroidal anti-inflammatory drug [NSAID] that can treat pain, inflammation, and lowers risk of stroke or blood clots) with food as indicated on the physician's order. 2. Administer Resident 223's Simbrinza Ophthalmic Suspension 1-0.2 percent (%) (Brinzolamide - Brimonidine Tartrate- used to treat increased pressure in the eye) between 8AM and 10AM. These failures had the potential risk of adverse effects (an undesired harmful effect resulting from a medication or other intervention) for Residents 228 and 223.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Two (2) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, yielded a facility medication rate of 8% for two (2) of four (4) sampled residents (Resident 228 and Resident 223) observed during medication administration (med pass). The medication errors were as follows: 1. Administer Resident 228's aspirin (a type of nonsteroidal anti-inflammatory drug [NSAID] that can treat pain, inflammation, and lowers risk of stroke or blood clots) with food as indicated on the physician's order. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: a. Label foods in the kitchen with item name and 'use by' date (the last date recommended for the use of the product) and/ or open date. b. Discard expired food items in the kitchen. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wrote4. During a review of Resident 126's admission Record, the admission Record indicated Resident 126 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of trigeminal neuralgia (a type of chronic pain disorder that involves sudden attacks of severe facial pain) and repeated falls. During a review of Resident 126's MDS, dated [DATE], the MDS indicated resident had an intact cognitive skill for daily decision making. MDS also indicated Resident 126 required substantial/maximal assistance with toileting hygiene, shower/bath self, upper body dressing, lower body dressing and putting on/taking off footwear. Resident 126 required supervision or touching assistance (helper provides verbal cures and/or touching/steadying and/or contract guard assistance as resident completes activity. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of two of 21 (Residents 39 and 29) residents, by failing: 1. To ensure the call light (initial communication between staff and residents) was within reach of Resident 39 when the resident needed to call for help to ask for water on 12/11/2024. 2. To provide Resident 29 with a touch pad call light (with a gentle touch, it will signal to notify a caregiver that assistance is needed) which is appropriate for the resident condition/needs. This deficient practice has the potential to delay in the necessary care and services and/ or needs not being met for Resident 39 and 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate with the primary physician and IDT and to collaborate with Hospice 1 regarding Resident 1's Responsible Party's (RP 1) request to place Resident 1 under hospice care (a program that gives special care to residents who are near the end of life and have stopped treatment to cure or control their disease) for one of 21 sampled residents (Resident 1). This deficient practice resulted in a delay or lack of coordination in delivery of hospice care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one (1) of two (2) medication carts (Medication Cart 2) as indicated in the facility policy by failing to ensure Resident 47's: a. open vial of Humalog (brand name for insulin lispro a fast-acting insulin [a hormone that helps regulate blood sugar levels and metabolism]) was labeled with an open date. b. 2 unopened Humulin N (brand name for NPH insulin which is an intermediate-acting insulin) KwikPens (brand name for a prefilled, disposable insulin pen that can be used to deliver insulin) were stored in the refrigerator. This deficient practice had the potential for adverse reaction in the event that these medications were administered to Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' meals were palatable (refers to the taste and/or flavor of the food) for one of two sampled residents (Resident 34) in accordance with the facility policy. This failure had the potential to result in dissatisfaction, decreased food intake and place Resident 34 at risk for unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two sampled residents (Resident 1) and Resident 1's Responsible Party (RP 1) were informed of the resident's rights and services upon admission at the facility. Resident 1 was admitted to the facility on [DATE] at 8:40 PM, Resident 1 and RP 1's did not receive the facility's admission packet (an admission agreement that explains the resident's rights and responsibilities in the nursing home) until 10/25/2024. This deficient practice had the potential to negatively impact Resident 1's rights to be informed.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent elopement (leaving the facility without the staff's knowledge and/or supervision) for one (1) of two (2) sampled residents (Resident 1) when Resident 1 left the facility through his room's sliding door and to the facility's emergency exit door located near the laundry room (Exit Door 1) and the alarm did not go on. This failure resulted in Resident 1 eloped on 10/28/2024 between 1:38 AM to 1:48 AM and Resident 1 was found on 10/29/2024 around 3:40 PM along Street 1 and 2 chatting with unknown individuals and the reisdent refusing to return to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility ' s policy and procedure titled Administrative Manual under Nursing Services, Nurse staffing: (NHPPD) (NHPPD-form indicating projected and actual daily nursing hours) by: 1. Failing to indicate in the posted NHPPD form the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care on 9/4/2024, 9/6/2024, 9/9/2024, and 9/11/2024. 2. Failing to ensure the NHPPD form is posted in a prominent location readily accessible to resident and/ or visitors for viewing. 3. Failing to ensure the NHPPD form for the following dates 8/30/2024 to 9/1/2024 were completed and available for review when requested on 9/10/2024. This deficient practice resulted in inaccessibility of the accurate daily number of clinical staff giving direct care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its Facility Initiated Transfer /Discharge policy for (1) of three (3) sampled residents (Resident 1) by failing to: 1. Complete the Transfer Assessment form before transferring Resident 1 to Facility 2. 2. Complete a Discharge Summary to include documentation of Resident 1's basis for transfer to Facility 2. 3. Obtain a Physician's order for Resident 1 to be transferred to Facility 2. 4. Inform Resident 1 of which facility he was being transferred to. This deficient practice has the potential for an unsafe and inappropriate discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three (3) sampled residents (Residents 1) did not elope from the facility as indicated in the facility's policy and procedure by failing to: 1. Provide adequate supervision on 8/28/2024 at 7PM. 2. Accurately assess Resident 1 for Risk for elopement (a form of unsupervised wandering that leads to the resident leaving the facility) 3. Develop a resident centered care plan to include specific interventions such as supervision to prevent elopement and implement use of wander guard (a bracelet that can be integrated with a resident's security system to alert staff when residents have wandered). This deficient practice resulted in Resident 1 from eloping the facility on 8/28/2024, which placed the resident at risk for injury, harm, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure that three (3) of 4 sampled licensed nursing staff were competent to provide the necessary nursing services and care for the residents in accordance with the facility ' s policy and procedure (P&P) by: 1. Failing to evaluate and ensure that Registered Nurse 1 (RN 1) was competent and had the skill sets necessary before providing care to the residents in the facility. 2. Failing to evaluate and ensure that Licensed Vocational Nurse 1 (LVN 1) and LVN 2 were competent and had the skills sets necessary before providing care to residents in the facility. These deficient practices had the potential for residents not to receive appropriate and safe nursing care and services from facility licensed nurses, placing the residents at risk for injury or harm.

Inspectors wroteBased on interview and document review, the facility failed to ensure a safe environment for residents, staff, and the public by failing to provide: 1. Documented evidence of HCAI permit and approvals for roofing work. 2. Documented evidence of HCAI permit and approvals for installation of one of six Heating, Ventilation, and Air Conditioning (HVAC) units (HVAC unit #3). The California Department of Healthcare Access and Information (HCAI) monitors the construction, renovation, and seismic safety of California ' s skilled nursing facilities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the call light (a device found near a patient's bed or within reach that consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the patient's room) was within the resident's reach while in bed for one out of four sampled residents (Resident 3). This deficient practice had the potential to cause a safety issue such as fall and prevent Resident 3 from receiving medical attention when necessary.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive and resident-centered care plan to address the Peripherally Inserted Central Catheter (PICC; a thin, flexible tube that's inserted into a vein in the upper arm and threaded into a large vein near the heart) line for one out of four sampled residents (Resident 1). This deficient practice had the potential to cause inappropriate care of Resident 1's PICC line which can potentially result in PICC line infection and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for 2 of 4 sampled residents (Residents 1 and 2) by failing to: 1. Ensure that trash can was emptied when full in a Coronavirus 2019 (COVID 19; a highly contagious respiratory disease caused by the SARS-CoV-2 virus) isolation room (hospital room that keep patients separate from others to prevent the spread of infections) for Resident 1. 2. Ensure that Intravenous (IV) tubing (a flexible plastic tube that delivers fluids, medications, and other therapies into the body through a vein) was dated and labeled for Resident 2. These deficient practices had the potential to cause and spread infection within the facility among staff and residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan (a document that outlines the facility ' s plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) to provide interventions swollen (enlargement caused by a buildup of fluid in the tissues) left hand for one of one sampled resident (Resident 1) in accordance with the facility policy. This failure resulted in the lack specific care interventions for Resident 1 ' s left hand swelling, with the potential to worsen Resident 1 ' s left hand condition and function.

Inspectors wroteDuring an observation, interview, and record review the facility failed to provide a safe, clean, and homelike environment for two (2) of four (4) sampled residents (Resident 10 and Resident 81) for environment care area, as indicated on the facility policy when the residents' room wall paint were observed peeling, discolored, and patchy. This deficient practice can potentially affect the resident's mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide a communication board (a sheet of symbols, pictures, or photos that individual will point to, to communicate with those around them.) for two (2) of three (3) sampled residents (Resident 341 and 22) for activities of daily living (ADL) care area, in accordance with the facility policy. This deficient practice had the potential for unmet residents' needs, which can result to a decline in physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) out of three (3) sampled residents (Resident 77 and 340) for activities of daily living (ADL) care area were provided care and services to maintain good grooming and personal hygiene. 1. Resident 340 who was dependent with staff for ADLs was observed with incontinent brief, soaked with urine and soiled with stool. This deficient practice had the potential for Resident 340 to develop infection and skin breakdown which could result in the decline of the resident's wellbeing. 2. Resident 77's nails on both hands were observed as thick, with brownish discolorations and untrimmed. This deficient practice had the potential to result in a negative impact on Resident 77 quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct setting for three (3) of five (5) sampled residents (Residents 1, 36 and 76) for pressure ulcer care area, in accordance with the facility's policy and procedure. This deficient practice had the potential to place the residents at risk for skin integrity complications and pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for six (6) of seven (7) sampled residents (Resident 1, 23, 36, 45, 47, 68, and 83) for respiratory care area, in accordance with the facility's policy and procedure when: 1. Resident 83's oxygen humidifier was not dated. This deficient practice had the potential for the humidifier not to be changed timely that could lead to respiratory discomfort. 2. Resident 36's oxygen tubing was tied on the overhead trapeze (a triangle-shaped metal bar that hangs above the resident's bed, used to facilitate movement and positioning of a resident). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food and prepare food in sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) by failing to ensure: 1. Kitchen equipment and surfaces are free from dirt, dust, and debris 2. Proper storage of kitchen equipment to prevent contact with dirt 3. Dry storage room was free from boxes 4. Two bottles of food release spray (an aerosol spray used to release baked goods from pans) were dated and properly stored. 5. Expired food was not stored in the dry storage room and kitchen 6. Food items stored in the refrigerator were labeled 7. Food items stored in two of two freezers were dated and labeled 8. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide dignity to one (1) of 2 sampled residents (Resident 41) for dignity care area, in accordance with facility's policy when Resident 41 was referred and called by staff a feeder. This deficient practice had a potential to affect Resident 41's emotional and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the advance directive (written statement of a person's wishes regarding medical treatment which were made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were placed in the resident's chart with the Physician Orders for Life-Sustaining Treatment (POLST, a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the patient's current medical condition into consideration) for one (1) of two (2) sampled residents (Resident 77) for advance directive care area, as indicated on the facility policy. This deficient practice had the potential to cause conflict in carrying out Resident 77's wishes for medical treatment and resident's health care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive resident-centered care plan for two (2) of 22 sampled residents (Resident 36 and 22) per facility's policy. 1. Resident 36 did not have a have a care plan to include interventions for the use of low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) as indicated on the physician's order. 2. Resident 22 did not have a care plan to include interventions for the use of communication board. This deficient practice had the potential for residents' to not receive specific interventions to prevent decline in the resident's functional ability and may result in injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 21) for accident care area, was free of accident hazard by not providing padding to resident's bed side rails. This deficient practice may result in injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was no medication error (any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer) rate of greater than five percent (5%) for one (1) of two (2) residents (Resident 21). The facility had cumulative error rate of 7.69% with 26 opportunities observed during medication pass. Two medications (Flonase [medication used to treat allergy] and Dorzolamide HCL[Hydrochloride]-timolol [medication used to decrease pressure in the eye]) were omitted by Licensed Vocational Nurse 4 (LVN 4) on 1/12/2024. These deficient practices had the potential to result in the Resident 21's eye pressure to increase which could result in blindness. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the resident's medical record for one (1) of 22 sampled residents (Resident 45) by failing to ensure the facility has the correct physician's order in the resident's electronic health records (eHR) of the resident's code status (describes the type of resuscitation procedures the resident would like the health team to conduct if the resident's heart stopped beating and/or the resident stopped breathing). This deficient practice had the potential to result in improper delivery of care and services during a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one (1) of two (2) clothes dryer in safe operating condition, as indicated on the facility policy. This deficient practice had the potential to result to inability to get an accurate dryer temperature reading required to eliminate disease causing bacteria's, germs, and viruses on clothes and fabrics.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for one (1) of 22 sampled residents (Resident 9) by: 1. Leaving a used blood-stained alcohol pad on the floor 2. Leaving a used pair of clear gloves on the floor next to the trash can 3. Disposing two used chemstrips (a small, plastic strip that help test and measure the resident's blood sugar level) in the regular trash can. These deficient practices had the potential to result in the spread of diseases and infection.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate record of bed hold notification form (whenever a resident is transferred to a General Acute Care Hospital [GACH], the nursing home must allow the resident or family member to hold the residents bed for up to seven [7] days) and notice of proposed transfer/discharge for one (1) of 1 sampled Resident (Resident 1) in accordance with the facility's policy and procedure. This deficient practice had the potential for Resident 1/Responsible Party not to be aware of Resident 1's reason for transfer to GACH on 10/24/23 and had the potential to violate Resident 1's rights for proper discharge placement and treatment choice.

Inspectors wroteBased on interview and record review, the facility failed to identify and report an unobserved/unexplained injury requiring transfer to a hospital for examination and/or treatment to the California Department of Public Health (CDPH), law enforcement agency, and Ombudsman (an official appointed to investigate individuals' complaints against the facility) for one (1) of three (3) sampled residents (Resident 1) in accordance to the facility ' s policy and procedure. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.