Broadway by the Sea

Inspectors wroteBased on interview and record review the facility failed to provide the necessary care and services for one of 11 sampled residents (Resident 2) by failing to:1. Ensure Resident 2 was monitored and reassessed for a fever with temperature of 100.1.2. Ensure Acetaminophen (medication used for fever) 325mg (mg-metric unit of measurement) tablets oral were administered as ordered. These failures placed Resident 2 at risk for increased fever, dehydration and the potential to lead to infection and a decline in medical status.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services for two of two sampled residents (Resident 1 and Resident 2) by failing to administer 9 a.m. medications one hour before or after the scheduled time. This deficient practice placed Resident 1 and Resident 2 at risk for increased adverse drug reactions, increased symptoms and mismanagement of the medication regimen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) physician and power of attorney ([POA] decision maker) was notified of refusals of Ciclopirox cream (antifungal cream) treatment to both feet BID for tinea pedis (fungal infection) on 1/8/2026, 1/10/2026, 1/11/2026 and 1/12/2026. This failure resulted in Resident 1 not receiving treatment and care for four days and had the potential to cause infection, inflammation and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause foodborne illness (food poisoning) for 74 out of 84 total residents in the facility by failing to:1. Ensure a bag of mixed vegetables in the refrigerator were properly stored and labeled with an open date.2. Ensure a box of waffles were stored and sealed properly in the freezer.3. Ensure a bag of sweet potato fries were stored properly in the freezer labeled with an open date. These deficient practices had the potential to result in pathogen (germ) exposure and placed residents at risk for developing foodborne illnesses with symptoms including nausea, vomiting and diarrhea.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were up to date as per the facility's policy and procedure (P&P) regarding advance directives ([AD], a legal document of a resident's wishes regarding medical treatment) for four of five sampled residents (Resident 2, Resident 8, Resident 11, and Resident 86). These deficient practices violated the residents' rights to be fully informed of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for three of four sampled residents (Resident 11, Resident 33, and Resident 86). The facility failed to indicate: Resident 11 had a gastrotomy/feeding tube ([G-Tube], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems). Resident 33 was receiving Restorative Nursing Assistant services ([RNA] services helps residents regain and maintain physical function, mobility, and independence through specialized exercises, transfers, and positioning). Resident 86 was receiving RNA services. This deficient practice had the potential to result in inaccurate assessment and services for the residents due to inaccurate MDS assessments and care screening tool practices.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of three sampled residents (Resident 71 and Resident 49) related to: A. Failing to monitor and document Resident 71's intake and output for suprapubic catheter (a thin tube inserted through a small opening in the lower abdomen directly into the bladder to drain urine) daily accurately. B. Failed to monitor and document Resident 49's intake and output for urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) every shift and every 24 hours. This failure had the potential to result in Resident 71 and 49's needs not being met, affecting the residents' well-being, including significant changes in urine output being missed, and poor patient outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plans for two out of twelve sampled residents (Resident 5 and Resident 6) were revised to reflect their current plan of care by failing to ensure:a. The care plan for Resident 5 was updated to reflect his current nutritional needsb. The care plan for Resident 6 was updated to reflect his current urinary continence status This deficient practice had the potential for Resident 5 and Resident 6 to not receive person centered care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 3 and Resident 2) who received hemodialysis (HD-process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, as evidenced by:A. Failing to ensure Resident 2 received Hemodialysis twice a week as orderedB. Failing to ensure resident 3 who received hemodialysis had an emergency kit at resident's bedside. These failures had the potential to result in Resident 2 suffering from complications such as fluid overload (too much fluid builds up in the body, causing swelling), electrolyte imbalance (the body has too much or too little of essential minerals), and dangerous buildup of toxins/waste and Resident 3 receiving delayed intervention during accidental bleeding.

Inspectors wroteBased on interview and record review, the facility failed to educate and offer the COVID-19 (a highly contagious infection ) vaccination (medication to reduce risk for infection) for the 2025-2026 respiratory infection season (October 2025 - March 2026) for one of five sampled residents (Resident 7) and all staff. These failures had the potential to result in spreading the COVID-19 virus.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents, Resident 31, received their meal tray at the same time as their roommates This deficient practice has the potential to compromise residents' dignityFindings: During a review of the admission Record indicated Resident 31 was admitted to the facility on [DATE] with the diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), osteomyelitis of left ankle and foot (inflammation of bone, due to infection) and non-pressure ulcer (a small open wound found on the skin) of left heel and midfoot. During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool) dated 12/20/2025, the MDS indicated the resident had the ability to make self understood and the ability to understand others. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of five sampled residents (Resident 60). This failure had the potential to delay staff response and prevent Resident 60 from receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when Resident 9 refused medications for one of three sampled residents (Resident 9). This failure had the potential to result in delayed care to address the effects of Resident 9's refusal of medication.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse reporting and prevention policy by failing to report an injury of unknown origin to to the California Department of Public Health (CDPH - state licensing and certification agency) and other officials which includes the Long-Term Care Ombudsman, Law Enforcement, and Licensing Agency for Based on interview and record review, for one of one sampled residents (Resident 9). Theis deficient practice resulted in CDPH being unaware of the injury of unknown origin and possible abuse allegation to conduct a timely investigation. This deficient practice had the potential for information to be lost and/or forgotten.

Inspectors wroteBased on interview and record review, the facility failed to follow it's policy and procedure (P&P) titled, Fall Management System, for one out of two sampled residents (Resident 27) by not investigating an allegation of a fall incident. This deficient practice had the potential for an actual fall for Resident 27 to not be discovered and probable causal factors to not be identified.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 16) was seen in a timely manner by a Registered Dietician (RD) after an order for a RD consult was placed due to poor oral (PO) intake. This deficient practice had the potential to lead to unintentional weight loss for Resident 16 due to unaddressed poor oral intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain management for one of three sampled residents (Resident 8), as evidenced by failing to assess and document Resident 8's pain level and the effectiveness of the pain medication before and after giving the pain medication. This failure had the potential to result in Resident 8 not being able to get quality sleep, decreased energy and decreased participation in activities and therapy sessions due to unrelieved pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to document medication administration for one of three sampled residents (Resident 6). This failure had the potential to result in Resident 6 receiving duplicate doses of acetaminophen (medication used to reduce pain or fever) which places residents at risk for liver problems due to taking too much acetaminophen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 16)'s diagnoses list was updated to reflect her dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells) diagnosis. As a result of this deficient practice, Resident 16 was receiving medications for a dementia diagnosis that was not listed as one of her current problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures by failing to ensure Restorative Nurse Aide (RNA -provides specialized care to help patients recover and keep their functional abilities) 1 wore Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for one of three sampled residents (Resident 71) who was on Enhanced Barrier Precaution (EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent MDRO spread where direct contact is likely). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' rooms had 80 square feet ([sq ft], a unit of measurement) per resident in multiple resident rooms. This deficient practice had potential for affecting the residents' quality of life, safety, health and provision of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders for one out of three sampled residents (Resident 1) who was receiving care from a podiatrist (foot doctor). This deficient practice resulted in Resident 1 not receiving Ciclopirox n 8% (medication to treat nail fungus) for two months (7/14/2025 to 9/16/2025) and had the potential to delay healing of the left and right great toes.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain Office Visit Summaries from the outpatient physician visits on 7/1/2025 and 9/3/2025 to follow physician treatment recommendations for one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1 not receiving treatment for Onychomycosis (toenail fungus) of the right and left great (big) toes for two months (7/14/2025 to 9/16/2025).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was exhibiting signs and symptoms of depression (serious mental condition that negatively affects how one feels, thinks, and acts), and had an order for psychiatric evaluation (medical doctor specializing in the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) on 2/27/2025, 3/11/2025, and 6/3/2025, was seen by the psychiatrist as ordered and signs and symptoms of depression were monitored as indicated in Resident 1's Care Plan. These failures resulted in Resident 1 experiencing worsening symptoms of depression which included loss of interest in activities and excessive sleepiness. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled resident's (Resident 1) call light (a device used by residents to call for assistance from facility staff) was within reach. This deficient practice resulted in Resident 1 looking for but not being able to locate find her call light. This deficient practice had the potential for Resident 1 to get out of bed without assistance causing a fall and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three Licensed Vocational Nurses (LVN 2) license was active. This deficient practice resulted in LVN 2 working 61 shifts with an inactive license.

Inspectors wroteBased on observation, interview and record review, the facility failed to intervene and document wound care prevention and management according to professional standards of practice and per the facility ' s policy and procedure titled, Skin and Wound Monitoring and Management, for 2 of 3 sampled residents (Residents 1 and 2) by failing to: 1. Document wound care treatments ordered by the physician in the treatment record for Resident 1. 2. Document Resident 2 ' s wound measurements upon admission. 3. Order and treat Resident 2 ' s moisture associated skin damage (MASD - skin damage caused from prolonged exposure to moisture) upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who was assessed at risk for falls with poor safety awareness, did not fall and sustained injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's untitled care plan, dated 7/5/2024, identifying the resident as fall risk, had specific interventions used and carried out to prevent the resident from falls and injuries. 2. Ensure untitled care plan, dated 7/5/2024, identifying Resident 1 as fall risk, was reviewed and revised after the resident's fall on 8/20/2024, to have specific interventions to safeguard the residents from future falls and injuries. 3. Ensure staff has taken precautions (unspecified) to prevent Resident 1 falls as indicated in untitled care plan dated 7/8/2024, for the anticoagulant (blood thinner) therapy. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2) who was a high risk for falls was supervised and assisted. The facility failed to ensure the 1:1 sitter (a health care professional who provides constant care and supervision for a patient) assigned to Resident 2 was frequently monitoring and providing visual checks while Resident 2 was in the restroom. This deficient practice resulted in Resident 2 sustaining three unwitnessed falls in the month of 1/2025.

Inspectors wroteBased on interview and record review, the facility failed to implement its Infection Prevention and Control Program by failing to: 1. Ensure all facility staff including registry staff (personnel provided by a placement service on a temporary or on a day-to-day basis) were tested according to local health department guidance. 2. Ensure all facility staff were provided in-services (a type of training that takes place in a nursing workplace to update nurses on the latest information and skills, which can improve patient care) regarding COVID-19 (a potentially severe respiratory illness caused by coronavirus and characterized by fever, coughing, and shortness of breath) protocols. These failures placed residents, staff, and the community at higher risk for cross contamination, and increased spread of COVID-19 infection in the facility and the community.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) grievances related to call lights were resolved to prevent recurrence. This deficient practice resulted in Resident 3 filling similar grievances on 12/2024 and 1/2025.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), nephrostomy tube (a thin, flexible tube that drains urine from the kidney into a bag outside the body) and suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) was monitored and treated. These deficient practices had the potential to result in infection, dislodgement (the action of something moving or being removed from a fixed position), an/or other complications related to Resident 1 ' s nephrostomy tube and suprapubic catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was assessed at a moderate risk for developing a skin injury and had intact skin upon admission, did not develop a Stage III (full thickness tissue loss - underlying fat tissue may be visible, but bone, tendon, or muscle is not exposed) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacro-coccyx area (tailbone) measuring nine centimeters [(cm) unit of measurement] in length, nine cm in width and 0.1 cm in depth for one of two sampled residents (Resident 40). The facility failed to: 1. Implement Resident 40's (untitled) care plan intervention to turn and reposition the resident every two hours, to prevent the resident from developing a pressure injury by relieving the pressure from the sacro-coccyx area. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) programs for two of 9 sampled residents (Resident 27 and 31) were modified by qualified and competent staff. 1. For Resident 27, Restorative Nursing Assistant 1 (RNA 1) and Restorative Nursing Assistant 2 (RNA 2) modified Resident 27's RNA program. 2. For Resident 31, RNA 3 modified Resident 31's RNA program independently. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure: a) a) One of two sampled resident (Resident 60)'s informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for a Seroquel (a psychotropic drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) to treat mental illness was updated. b) One of two sampled resident's (Resident 23) had a medical diagnosis indicated for use of haloperidol (psychotropic). This failure had the potential to for residents to receive unnecessary psychotropic medications which can lead to a risk of increased falls, confusion, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications appropriately for three (Residents 24, 69, and 140) of five residents observed during the medication pass. During medication pass, there was one medication error for Resident 24, one medication error for Resident 69, and five medication errors for Resident 140 for a total of 7 medication errors out of 31 opportunities. These medication administration errors resulted to a medication error rate of 22.58%.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 140) was free from significant medication error by failing to ensure Licensed Vocational Nurse (LVN)2 administered five medications individually and not crushed together. This deficient practice potentially resulted in unsafe combinations of medications and had the potential of altering the composition of medications rendering it less effective.

Inspectors wroteBased on observation, interview and record review, the facility: a. Failed to ensure facility staff 1did not leave medication on one of three residents (Resident 8)'s bedside table. b. Failed to ensure Resident 12's budesonide (class of medication used to treat inflammation - swelling) had an open date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure proper labeling of open dates for seven seasoning containers. 2. Ensure staff wore a hair net properly while handling dishes in the dishwashing area. These deficient practices had the potential to cause food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs) for three of eight sampled residents (Residents 15, 29, and 34) were completed by a Physical Therapist (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) and/or Occupational Therapist (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities). 1. For Resident 15, Occupational Therapy Assistant 1 (OTA 1) performed Resident 15's Quarterly JMA on 7/15/2024. 2. For Resident 29, OTA 1 performed Resident 29's Quarterly JMA on 8/8/2024. 3. For Resident 34, OTA 1 performed Resident 29's Quarterly JMA on 8/30/2024. [...]

Inspectors wroteCROSS REFERENCE TO F688 Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) services provided were accurately documented for two of nine sampled residents (Resident 27 and 31). a. For Resident 27, Restorative Nursing Assistant 1 (RNA 1) and Restorative Nursing Assistant 2 (RNA 2) failed to accurately document passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises provided during RNA sessions in October 2024 and November 2024. b. For Resident 31, RNA 3 failed to accurately document right upper extremity splint application. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Provide annual documentation verifying the review of their Infection Prevention and Control Program (IPCP) policies and procedures. b. Ensure the Director of Staff Development who was also the interim (temporary) Infection Preventionist Nurse (DSD/IPN), Licensed Vocational Nurse (LVN)1 and Certified Nurse Assistant (CNA)1 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while providing direct contact care to two out of three residents (Resident 1 and 40) who were on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct the quarterly Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference involving one of three sampled resident's (Resident 25) Family Member 1 (FM 1). This deficient practice violated Resident 25 and FM 1's rights to be informed and the right to participate in resident's plan of care.

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure that a resident was assessed to determine if the resident is capable to self-administer medications for one of one sampled resident (Resident 69). This deficient practice had a potential for resident to self-administer respiratory medications incorrectly resulting in subtherapeutic (below the level necessary to treat effectively) medication effects which can lead to unresolved wheezing (caused by narrowing or blacked airways in the lungs) or difficulty breathing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 25) was assessed for use and received informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and physician order for Resident 25's bolster (long pillows at the foot of the bed). The deficient practice resulted in a violation of resident rights to be free from restraints (any manual method, physical or mechanical device, equipment, or material that is adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement).

Inspectors wroteBased on interview and record review, the facility failed to report one of one resident's (Resident 25) unknown injury to the California Department of Public Health (CDPH), when Resident 25 was observed with left lower leg bent inward towards the resident possibly indicating fracture (broken bone) on 2/9/2023. This deficient practice resulted in CDPH's inability to investigate the report of unknown injury timely and had the potential for other cases of unknown injuries to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to investigate one of one resident's (Resident 25) unknown injury after Resident 25 was observed with the left lower leg bent inward towards the resident possibly indicating a fracture (broken bone) on 2/9/2023 and report the results of the investigation to the California Department of Public Health (CDPH) within five working days of the incident. This deficient practice resulted in CDPH's inability to investigate the report of unknown injury timely and had the potential for other cases of unknown injuries to go unreported.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident's (Resident 55) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) screening was completed upon readmission on [DATE]. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 55.

Inspectors wroteBased on observation, interviews and record review, the facility failed to initiate a care plan for the Restorative Nursing Assistant ([RNA] assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) for splinting (a technique that uses a device to immobilize (prevent movement) a joint or limb to help with pain control, injury stabilization, and/or tissue healing) for one out of two residents (Resident 31). This deficient practice had the potential to negatively affect the delivery of necessary care and services including skin breakdown, pain, or harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and monitor and document the condition of a suprapubic (a urinary catheter that is inserted into the bladder [a hollow organ that stores urine] from a small cut in the lower area of the stomach) catheter (a flexible tube inserted into an opening in the body) stoma (a surgical hole) site for signs and symptoms of infection, skin breakdown, unusual odor, and secretions. as ordered by the physician for one of two residents (Resident 61). This deficient practice has the potential to delay the detection of early signs or symptoms of infection.

Inspectors wroteCROSSREFERENCE TO F842 Based on observation, interview, and record review, the facility failed to provide treatment and services to one of eight sampled residents (Residents 27) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) by failing to provide Resident 27 with Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and mobility) passive ROM (PROM, movement at a given joint with full assistance from another person) exercises, three times a week as ordered. This deficient practice had the potential to cause Resident 1 to have a decline in ROM of both arms, contracture (loss of motion of a joint) development, and a decline in physical functioning such as the ability to eat, dress, and bathe.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Registered Dieticians recommendations to increase the tube feeding (medical procedure that provides nutrition, fluids, to people who are unable to eat or drink safely by mouth) was carried out in a timely manner. This deficient practice had the potential to result in the resident's weight loss which can result in negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident (Resident 34), who was diagnosed with post-traumatic stress disorder (PTSD - mental health condition that can develop after someone experiences or witnesses a traumatic even), received trauma informed care (a model that aims to provide effective mental health services by considering a person's past experiences with trauma). This deficient practice had the potential to result in resident re-traumatization and can be detrimental for the resident's psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed ta ensure the resident's rooms had 80 square feet per resident in multiple resident rooms. This deficient practice had a potential for affecting the residents' quality of life, safety, health, and provision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) did not receive unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior and used to treat mental health disorders). The facility failed to: 1. Ensure Resident 8 w, not prescribed and administered Ativan (a prescription medicine often used to treat people living with anxiety [extreme worry]) 1 milligrams ([mg] a unit of weight measurement), every four hours as needed (PRN) for agitation (feelings of irritability, mental distress, or severe restlessness) and shortness of breath (SOB) for 14 day, without documented indication for use. 2. Ensure Resident 8 was not administered Ativan 1 mg every four hours for six days along with other psychotropic medications (Seroquel and Risperdal), causing Resident 8 to be over sedated. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP 1) for one of five sampled residents (Resident 8) was informed when the dosage and frequency of Resident 8's medication ([Ativan] used to treat anxiety [extreme worry]) was changed. one of five sampled residents (Resident 8) Responsible Party (RP) was notified when Resident 8's medication dosage and frequency was changed. This deficient practice resulted in Resident 8's RP not being aware of or understanding the change in Resident 8's medication regimen and had the potential for unnecessary medication administration and side effects/adverse reactions to the unnecessary medication.

Inspectors wroteBased on interview and record, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of seven sampled residents (Resident 1) when Resident 1 sustained a reddish-purple discoloration to the left arm and right rib flank. This deficient practice resulted in the inability of CDPH to investigate Resident 1's injury of unknown injury in a timely manner and had the potential for facts related to the injury to be forgotten by staff.

Inspectors wroteBased on interview and record, the facility failed to conduct a investigation for one of five sampled residents (Resident 1) when Resident 1 reported he was attacked by nursing staff and when reddish-purple discoloration was found on Resident 1's the left arm and the right rib flank area. This deficient practice resulted in the inability of the facility to determine what might have been the cause of Resident 1's injury and had the potential to recur.

Inspectors wroteBased on interview and record review, the facility failed to ensure all items on the inventory list for one of three sampled residents (Resident 1) was accounted for when the facility failed to review and sign Resident 1 ' s Inventory List with Resident 1 ' s Power of Attorney ([POA] legal authorization for a designated person to make decisions about another person ' s property, finances, or medical care), following Resident 1 ' s discharge from the facility on 3/12/2024. This deficient practice resulted in the inability of the facility to determine if Resident 1 ' s belongings were accounted for before giving them to Resident 1 ' s POA and the inability to look for any missing items. This deficient practice had the potential for other residents ' property to be unaccounted for.

Inspectors wroteBased on interview and record review, the facility failed to report Resident 1 ' s debit card was missing to the California Department of Health (CDPH), State Long Term Care Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) and the local police department (PD) within the regulated time frame of 24 hours for one of three sampled residents (Resident 1). This deficient practice resulted in the delayed investigation of Resident 1 ' s missing debit card, by CPDH, which resulted in 325 unauthorized debit card transactions totaling approximately $11,254.00 from 12/21/2023 through 5/23/2024.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents, who were assessed as a high risk for falls, had preventative measures implemented to prevent them from falls and injuries for three out of eight sampled residents (Residents 1, 3, and 4). The facility failed to: 1. Implement interventions including landing mats and bed alarm for Resident 1 as care planned Resident 1 had a history of falls on 10/24/2023 and 11/20/2024 and was assessed as a high fall risk. 2. Ensure Licensed Vocational Nurse (LVN 1) had knowledge of Resident 1's high risk for fall, how to access Resident 1' Care Plans, to implement interventions to safeguard Resident 1 from falls and injuries, and knowledge of facility's protocol for falls. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify facility and resident care issues, develop and implement appropriate plans of action to ensure the QAA/QAPI committee systematically implemented and evaluated measures to monitor, review, and analyze data for performance improvement facility issues such as implementing a fall prevention program, that facility staff are educated on, designed to prevent [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Interdisciplinary ([IDT] Resident ' s health care team members from different specialties working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting following a readmission from a General Acute Care Hospital (GACH), involving one of six sampled residents (Resident 1) and their responsible party (RP), was held. This deficient practice violated Resident 1 and RP 1 ' s right to be an active participant in Resident 1 ' s plan of care and services with the IDT and delayed the discussion of needed care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident, who had physician ' s treatment orders for skin scratches, received the treatment for the scratches, for one of eight sampled residents (Resident 5). This deficient practice resulted in Resident 5 not receiving the treatment as ordered and had a potential for Resident 1 to have further decline in skin integrity due to not receiving the ordered treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 who was contracted through a nurse Registry (an agency that provides qualified staffing) to work at the facility, received abuse training and orientation (a one-of event that aims to welcome the employee, help them fit in quickly, and navigate their role and the company) before being assigned resident care. This failure had the potential to result in the inability of the facility to ensure that CNA 1 knew the abuse prevention regulations as mandated by the California Department of Public Health (CDPH) and per their facility ' s policy and procedure (P&P). This deficient practice had the potential to place residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all food items stored in one of two kitchen refrigerators were labeled and dated, and the expired food was not stored in the refrigerator. This deficient practice had the potential to result in the residents ingesting expired food and could place residents at risk for foodborne illness (an illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and could lead to symptoms such as nausea, vomiting, stomach cramps and diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures by ensuring staff wore the appropriate personal protective equipment (PPE equipment worn to minimize exposure to infections and hazards) prior to entering a contact isolation (a type of infection control for resident's that have infections that are spread by contact) room for 1 of 2 residents (Resident 185). This deficient practice had the potential to spread diseases and infection to other residents, and staff.

Inspectors wroteBased on observation, interview and record review, facility failed to attend to Resident16's need during medication administration by Licensed Vocational Nurse. (LVN1). Resident 16 was provided with a very cold icy water in the morning during medication administration, resident 16 complained about water been very cold for her to take medication, LVN1 stated water is fresh from kitchen and did not address the resident's need and walked away from the room. This deficient practice resulted in Resident 1 shivering, not been able to consume water with medication as desired and freezing with cold.

Inspectors wroteBased on interview and record review, facility failed to provide advance directive to Residents 16 . This deficient practices had the potential for Resident 16's right to refuse or request medical treatment during medical emergencies where resident and family are not available/capable of making decisions.

Inspectors wroteBased on observation, interviews and record review, facility failed to provide : a. a clean urinal with lid cover and toilet bowl with splashes of feces for one of one sampled resident. b. a comfortable temperature environment for resident's room for3 out of 10 sampled rooms had very low temperatures at 66-degree Fahrenheit, These deficient practices resulted in resident's rooms producing bad odors, freezing cold, and uncomfortable for residents staying in the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall prevention interventions for one of five sampled residents (Resident 386) who had high risk for falls. This deficient practice had potential to result in falls and serious injury related to fall for Resident 386.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement prevent aspiration (inhaling small particles of food or drops of liquid into the lungs) precautions for one of 15 sampled residents (Resident 12), who was receiving nutrition by gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), by failing to ensure the resident's head of the bed was elevated during enteral (feeding through stomach) feeding. This failure placed Resident 42 at risk for aspiration that can lead to lung problems such as pneumonia (an infection of the lungs that can cause serious harm) and other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor one of one sample resident (Resident 55)'s meal preference, resulting in Resident 55 getting pancakes when the pancake is listed as one of their dislikes. This deficient practice had the potential to result in weight loss for residents who did not receive the correct food items of their preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's rooms had 80 square feet per resident in multiple resident rooms. This deficient practice had a potential for affecting the residents' quality of life, safety, health, and provision of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately implement outbreak response measures (acts and procedures to minimize the spread of a disease) when a Coronavirus disease ([COVID-19] a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) outbreak (when one or more residents who have resided in a skilled nursing facility [SNF] for seven days or more test positive for Covid-19) occurred at the facility on 9/18/2023 for 57of 84 sampled residents. The facility failed to: 1. Ensure a certified nursing assistant (CNA 2) wore a disposable isolation gown and gloves when she was within two feet distance from a COVID-19 positive Resident 1. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess the need for and offer the pneumococcal vaccine (a vaccine used to prevent pneumonia [inflammation of the lungs], meningitis [inflammation of the brain] and sepsis [occurs when chemical released in the bloodstream to fight n infection trigger inflammation throughout the body]) for 2 of 5 sampled residents (Residents 2 and 3). This deficient practice resulted in Residents 2 and 3 not being protected against pneumonia and placed them at risk for acquiring pneumonia and transmitting it to other vulnerable residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled resident's, (Resident 1) adult disposable brief was checked against her will. This deficient practice resulted in Resident 1 feeling violated, humiliated and unsafe.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse reporting policy by not reporting allegations of physical abuse to the California Department of Public Health (CDPH) in a timely manner for one out of three sampled residents, Resident 1. This deficient practice had the potential for the underreporting of abuse incidents and a delay in investigation of abuse allegations, placing Resident 1 at risk for further abuse.