California Home for the Aged

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 1), when Resident 1 was identified as being at risk for falls with a history of seven falls in the facility and the care planned intervention of a 1:1 (continuous observation and support provided by one qualified staff member to one resident) was not implemented and Resident fell on 7/18/25. This failure resulted in Resident 1 experiencing a witnessed fall, from the bed onto the floor on 7/18/25. After the fall Resident 1 experienced pain, discoloration and tenderness to the left shoulder and was sent to the general acute care hospital (GACH) for evaluation. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a psychotropic medication was addressed on the comprehensive care plan for 1 (Resident #5) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses administered medications in accordance with professional standards of practice for one of three sampled residents (Resident 1), when Resident 1 received medications that were not prescribed for her on 8/20/24. This failure resulted in Resident 1 receiving medication not prescribed for her which had the potential to place Resident 1 at risk for adverse drug effects (an injury resulting from medical intervention related to a drug that includes medication errors).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable homelike environment for three of 15 sampled residents (Residents 1, 29 and 81) when the air vents (an opening which allows air to pass out of or into a room) in Resident 1, 29, and 81's rooms were covered with black and brown stains and had dust in between the slits of the vent. This failure resulted in Residents 1, 29, and 81 not being provided a comfortable, homelike environment and had the potential to cause the residents to experience illness from breathing in dust from the air vents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 22 sampled residents (Residents 49, 80, 37 and 4) when: 1. Residents 49 and 80 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 49 and 80 to be injured while using the side rails. 2. Resident 37 had an order of ipratropium bromide (medication used for breathing) via hand-held nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled through a connected mouthpiece or facemask) once a day for respiratory illness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for four of 12 sampled residents (Residents 25, 52, 55 and 66) when: 1. Registered Nurse (RN) 1 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 25's medications. This failure resulted in inaccurate charting and placed Resident 25 at a risk to not receive the medications ordered. 2. RN 1 did not follow the medication administration direction when she applied a lidocaine patch (medication patch applied on top of the skin for relief of pain) to Resident 25's left upper arm. This failure had the potential to put Resident 25 at risk for skin irritation. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when: 1. Registered Nurse (RN) 1 did not administer metoprolol (medication used to treat high blood pressure and pulse). This failure resulted in Resident 25 not receiving her blood pressure medication as prescribed by the physician and had the potential for Resident 25 to have elevated or low blood pressure and pulse and serious medical condition. 2. Licensed Vocational Nurse (LVN) 4 did not follow direction on the medication label to administer with breakfast when she administered Resident 55's potassium chloride (medication used to treat hypokalemia [low potassium level]). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles when two of two improper medication storage and labeling occured for: 1. Resident 5's hydromorphone (medication used to treat pain), hydrocodone-acetaminophen ( a narcotic medication used to treat pain) and lorazepam (medication used to treat anxiety) were found repacked in smaller plastic bags with no labels and placed back in the plastic medication container from the pharmacy. These failures had the potential for Resident 5 to not receive the right medication which could lead to more serious medical conditions and had the potential for drug diversion (abuse of prescription drugs or their use for purposes ot intended by the prescriber). 2. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide residents with a well-balanced diet to meet their nutritional needs for: 1. Three of five sampled residents (Resident 44, Resident 74 and Resident 83) when the Residents had a physician order for a supplement that was discontinued, and the Residents continued to receive the supplement. 2. Two of the five sampled residents (Resident 75 and Resident 30) when the Residents did not have a physician order for a chopped diet. This failure resulted in Resident 44, Resident 74 and Resident 83 receiving a discontinued supplement and had the potential to result in Resident 75's and Resident 30's nutritional needs not being met.

Inspectors wroteBased on observations interviews and record review, the facility failed to ensure two of the seven sample residents (Resident 13 and Resident 21) small portion diet were not followed according to their alternate menu for lunch on March 25, 2024. The failure had the potential result to not meet the resident's caloric intake and contribute to weight loss, further compromising the medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food was prepared in accordance with professional standard for food service safety when one of two sampled kitchen staff (Cook 2) did not have a beard restraint while preparing food. This failure had the potential for [NAME] 2's hair to fall into the food and caused contamination.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards when: 1. One of four residents (Resident 52) medical record did not reflect when change of the humidifier bottle (medical devices filled with water that increase the humidity in the oxygen being delivered) and amount of oxygen administered was not accurately documented. This failure placed Resident 52 at risk of the humidifier bottle not being changed timely, the water becoming stagnant (stale or foul), oxygen would not be humidified leading to dry, cracked and bleeding mucosal membranes (the moist outer layer that lines various cavities in the body) and receiving the incorrect amount of oxygen. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safe infection control measures for two of three sampled residents (Resident 2 and Resident 4) when: Resident 2's urinary catheter bag (a tube that is inserted into the bladder, allowing the urine to drain freely into an attached bag), and Resident 4's urinary tubing was observed lying on the floor. This failure had the potential to spread harmful bacteria (microorganisms that can be found on surfaces and in the body), infections to both Resident 2 and Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure titled In-service Training to ensure Licensed Nurses (LNs), Certified Nursing Assistants (CNAs) and ancillary (additional) support staff received and demonstrated competency to prevent and recognize resident abuse and the necessary skills and techniques necessary to care for residents with Dementia [a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning] when: 1. 36 of 67 CNAs had not attended and completed the 2023 annual mandatory in-service training for Dementia Module 1 titled Caring for Persons with Dementia. 2. 47 of 67 CNAs had not attended and completed the 2023 annual mandatory in-service training for Dementia Module 4 titled More than Words. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for two of two sampled residents (Resident 2 and Resident 26) when Resident 2 and Resident 26's urinary catheter (tube inserted into the bladder through the urethra, to drain freely into a connected bag) bags were not placed in a dignity bag (a bag the catheter drainage bag into to shield the resident's urine from view) and were visible from the hall outside the resident's room. This failure violated Resident 2 and Resident 26's need for urinary catheterization to remain private to ensure their dignity and respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 65) when Resident 65's functional limitation in range of motion was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 65's care needs not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed for one of five sampled residents (Resident 27) when Resident 27 was diagnosed with major depressive disorder (persistent feeling of sadness and loss of interest), dementia (loss of of cognitive functioning-thinking, remembering and reasoning) and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and was started on psychotropic medications (medications used to treat mental health disorders) on 12/2/19. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff with the appropriate competencies and skill sets to provide nursing services to ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when one of four nursing staff (Infection Preventionist-IP) did not receive a competency skills check after being hired. This failure had the potential to place residents' at risk of being exposed to the spread of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs for one of seven sampled residents (Resident 25) when Resident 25's metoprolol (medication used to treat high blood pressure) was not available for administration for 1 day (3/27/24). This failure had the potential for Resident 25's blood pressure to be uncontrolled and lead to serious medical condition such as a stroke (a loss of blood flow to part of the brain, which damages brain tissue).

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public when one of three medication rooms (Station 5) was observed with only one of four fluorescent lights was working. This failure had the potential for distribution of the wrong medications for residents and for staff to trip and fall.

Inspectors wroteBased on interview and record review, the facility failed to have an infection prevention and control program that included an antibiotic stewardship program that ensured residents who required antibiotics were prescribed the appropriate antibiotic, when the Infection Preventionist (IP) was unaware one of 21 sampled residents (Resident 67) who tested positive for extended spectrum beta-lactamase (ESBL- enzymes produced by a variety of gram negative bacteria with an increased resistance [not easily killed by] to commonly used antibiotics) and the physician was not notified of the lab results, and the resident was treated with an antibiotic her infection was resistant to. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality when: 1. The facility's pain assessment tool for cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) residents, Pain Assessment in Advanced Dementia (impairment of at least two brain functions, such as memory loss and judgment) (PAINAD), was not used for one of 22 sampled residents (Resident 67). This failure had the potential to result in Resident 67's pain going unnoticed and untreated, which could delay healing time, disturb sleep and activity patterns, reduce function, and reduce quality of life. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory (network of organs and tissues that help you breathe) care and services in accordance with professional standards of practice for four of five sampled residents (Residents 25, 39, 52, and 55) when: 1. Resident 25 had a humidifier (a container with sterile water used to prevent dry airway when breathing oxygen) with an outdated label (3/9/22); 2. Resident 39 had a humidifier with an outdated label (4/7/22); 3. Resident 52 had a humidifier with an outdated label (4/10/22); 4. Resident 55's oxygen humidifier and tubing were not dated; and 5. A non-licensed staff member (Central Supply [CS]) routinely changed residents' oxygen humidifiers and tubing, against the facility's policy and procedure titled, Oxygen Concentrator. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 20 of 22 licensed nursing staff (LN) possessed the competencies required to provide for residents' needs, when annual competency evaluations were not documented as completed in 2021. This failure had the potential for staff to not possess the appropriate skills and competencies to assure residents' safety and provide appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards, when: 1. The mechanical soft (chopped to make the food soft and easy to eat) salad located on the lunch assembly line was 56 degrees Fahrenheit (F- scale used to measure temperature) (acceptable temperature is below 41 degrees F) when measured with a food thermometer. This failure had the potential to place residents at risk for complications from foodborne illness (sickness caused by bacteria, viruses, parasites, or toxins). 2. Individually wrapped cookies and crackers were stored in three easily accessible snack bins. The individually wrapped cookies and crackers and the bins were not labeled with a use-by date. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of communicable disease and infections when: 1. One of five sampled residents' (Resident 68) nasal cannula (device used to deliver oxygen that is placed in a resident's nose) was observed on the floor in Resident 68's room. This failure had the potential to result in transmission of organisms (germs) from the floor, onto the nasal cannula and to Resident 68. 2. Two of four Licensed Nurses (Licensed Vocation Nurse [LVN] 1 and LVN 3) failed to perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizer) prior to the administration of medications for three of 11 residents (Residents 69, 71 and 428). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and ensure their policy and procedure (P&P) titled, Mandatory COVID-19 (communicable, respiratory disease that can cause severe illness in some people) Employee Vaccination Policy was followed, when the facility did not follow their process for granting non-medical exemptions, four of 19 staff members were inaccurately documented as having a non-medical exemption, and one nursing student was marked as having a non-medical exemption, without documentation of the exemption. This failure resulted in 93.8% (percent- unit of measurement) of staff being vaccinated for COVID-19, which placed residents at risk of being exposed and contracting COVID-19 from staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan for one of three sampled residents (Resident 73), when Resident 73 was admitted with hearing aids and the facility did not establish a care plan with interventions to address Resident 73's hearing needs. This failure had the potential to result in Resident 73 not having her hearing needs met.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan with measurable objectives and timeframes for one of 19 sampled residents (Resident 52), when Resident 52 required oxygen at night and a care plan was not developed to address Resident 52's respiratory needs. This failure had the potential for Resident 52's respiratory needs to be not met, which could lead to respiratory issues and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 55 and Resident 44) with an indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder) received appropriate care when: 1. Resident 55's indwelling urinary catheter had sediment (substances present in urine) trapped in the tubing and the physician was not notified; and 2. Resident 44's indwelling urinary catheter bag was partially folded and placed sideways in the catheter bag (bag used to cover the urinary catheter bag for privacy), preventing the free flow of urine. These failures placed Residents 55 and 44 at risk for urinary tract infections (infection in any part of the urinary system, the kidneys, bladder, or urethra).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 25), that received dialysis (treatment that uses the blood stream to filter out wastes in the body for people whose kidneys are failing) treatments, received ongoing assessments, when the facility did not perform post (after) dialysis assessments (includes vital signs [clinical measurements including heart rate, temperature, respiration rate and blood pressure that indicate the state of a resident's essential body functions], access site [used for connecting to a machine that filters blood during treatment] assessment, and condition of resident) three out of five days (4/8/22, 4/11/22, 4/13/22). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an annual gradual dose reduction (GDR-tapering of a medication dosage to determine if symptoms, conditions, or risks can be managed by a lower dose or it can be discontinued) of antipsychotic medication (medication for the treatment of psychosis [involves a loss of contact with reality and can feature hallucinations and delusions]) in accordance with the facility policy and procedure titled Medication Monitoring Medication Management, dated 2007, for one of five sampled residents (Resident 70) when Resident 70 was prescribed and administered an antipsychotic medication and the previous effort to conduct a GDR was 2/20/21. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's medication error rate did not exceed five percent, when two of 25 medication administration opportunities observed were not administered in accordance with facility policy and procedure (P&P) and standards of practice. This failure resulted in a medication error rate of 8% (percent- unit of measurement) and placed Resident 63 at risk for drug interaction and clumping of medications, which could result in plugging of the gastrostomy tube (G-tube- a tube surgically inserted through the abdominal wall that brings nutrition directly to the stomach) and prevent Resident 63 from getting the full therapeutic effect of all administered medications and nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow one of five sampled residents' (Resident 16) food preferences and dislikes, when Resident 16 received canned fruit instead of the preference for fresh fruit on her meal tray for lunch on 4/18/22. This failure had the potential to result in decreased food consumption for Resident 16.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident was offered the influenza (viral infection that attacks the respiratory system - your nose, throat and lungs) vaccine annually, when one of five sampled residents (Resident 64), was last offered the influenza vaccine in 2013, and no further education, offering, or declination (refusal) was obtained. This failure resulted in Resident 64 and/or their responsible parties (a person other than the resident, designated to make health care decisions on behalf of the resident), who had previously refused the vaccine, to not receive education and be offered the vaccine annually.